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VOLUME III NUMBER 4 



THE CLINICS 



OF 



John B. Murphy, M.D. 

AT 

MERCY HOSPITAL, CHICAGO 



AUGUST, 1914 




PUBLISHED BI-MONTHLY BY 

W. B. SAUNDERS COMPANY 

PHILADELPHIA AND LONDON 



COPYRIGHT, 1914, BY W. B. SAUNDERS COMPANY. ALL RIGHTS RESERVED 

PUBLISHED BI-MONrHLY (siX NUMBERS A YEAR), BY W. B. SAUNDERS COMPANY, WEST WASHINGTON SQUARE, 

PHILADELPHIA. PRICE PER YEAR: $8.0o; FOREIGN, 35 SHILLINGS 

Entered as second-class matter April 25, 191 2, at the Post Office at Philadelphia, Pennsylvania, under 

the Act of March 3. 1879 



CONTENTS 



PAGE 



MiTRPHY's Clinical Talks on Surgical and General Dl\gnosis . . . 617 

\\cn< Varieties; Symptoms; Management; Illustrative Cases 617 

rous Uterine Fibroid— The Relations of Uterme Tumors to 

ustrual Flow— Differential Diagnosis 653 

Arthroplasty of Hip v^ ' •. T^ V^^r .......... 663 

(Meeting of the International Surgical Congress at Mercy Hos- 
pital, Tuesday, April 21, 1914) 
Partial Ankylosis of the Hip with Bony Lipping of the Acetabular 

Margin.— Arthroplasty 674 

Metastatic Arthritis of the Hip Following Tonsillitis.— Lipping of 
the Acetabulum and Femoral Head Producing Partial Anky- 
losis.— Arthroplasty 681 

1;. !.\- Ankylosis of Multiple Joints.— Arthroplasty of the Hip 690 

llony Ankylosis of the Hip, with Some Absorption of the Head of 

the Femur. — Arthroplasty 696 

Ascending Root Neuritis Following Amputation of the Cauda 

Equina Close to the Conus 705 

Maugnant Papillomatous Cyst of the Breast. — ^Differential 

Diagnosis.— Operation 7" 

Paralytic Ileus from Cryptogenic Peritonitis 719 

Old Ununited Colles' Fracture. Open Reduction. — Nailing of 

THE Fragments 731 

Left Facl\l Nerve Paralysis of Congenital Origin. — Macro- 

gnathla. — Spinofaclal Nerve Anastomosis 745 

Paralysis of the Right Facial Nerve the Result of a Basal 
Skull Fracture. — Fracture of the Stylold Process. — 

Spinofacul Nerve Anastomosis 751 

Intra-uterine Fibroid. — Hysterectomy 761 

Paget's Cancer 769 

Carcinoma of the Rectum with Ulceration. — Iliac Sigmoidos- 

TOMY.— Radical Excision 775 

Second Operation 780 

Sarcoma of Humerus 783 

Second Operation. Exploration of Site of the Previous Operation 
I'r- f.aratory to Transplantation of a Piece of the Tibia to the 

I Iiiincrus 799 

CLRhiii:Lij\R Tumor. — Suboccipital Decompression 805 

(Discussion of Neurologic Symptoms by Dr. Charles L. Mix) 

Congenital Luxation of the Patella.— Reduction.— Excavation 

OF A Groove in the Femur for its Lodgment. — Plastic 

Operation and Imbrication of Joint Capsule to Hold it 

IN its New Position 817 

Recurrent Luxahon of Left Patella.— Internal Imbricating 
Fijvp Operation.— Paralysis of Right Leg with a Flail- 
joint at the Ankle.— Arthrodesis 839 

Postoperative Ventral Hernia Following Appendiceal Abscess. 

—Imbrication Operation 61 



n 



THE CLINICS 

OF 

Volume III JOHN B. murphy Number 4 



MURPHY'S CLINICAL TALKS ON SURGICAL 
AND GENERAL DIAGNOSIS 

ILEUS 

VARIETIES; SYMPTOMS; MANAGEMENT; ILLUSTRA- 
TIVE CASES 



HISTORY 

The patient, an unmarried woman aged twenty-five, entered 
the hospital October 12, 1913, complaining of generalized abdom- 
inal soreness and tenderness, most marked in the epigastric 
region, and vomiting of a watery, sour material, dark green in 
color. She is also constipated, and has been so for the last 
seven years. Her abdomen is distended. 

Her present trouble began on Monday, October 6, 19 13, 
with a sense of fulness in the epigastric region, most marked 
after meals. She did not vomit. Her bowels were constipated. 
This status continued until Thursday, October 9th, when, while 
eating dinner, she developed an excruciating, cramp-like pain, 
which began in the epigastric region and soon became more or 
less generaUzed over the entire abdomen. This pain continued 
until 3 p. M., when the doctor who was called administered J4 
grain of morphin and xio" grain of atropin. About half an 
hour later she vomited; thevomitus was dark green, very sour, 
and caused a burning sensation in her throat. She felt some- 
what reHeved after vomiting. Since then she has been vomiting 
nearly continuously, and the pain has continued more or less 
generalized over the abdomen. She has been given }4 grain 
doses of morphin with yIt grain of atropin on an average of 
three times a day since October 9th. Her bowels have not 
moved since the onset of the present trouble (October 6th) until 
this morning (Sunday, October 12th), when she was given an 
enema. She then passed much flatus and some fecal matter. 
During the first twenty-four hours of her trouble she did not 

617 



5i8 CLINICS OF JOHN B. MURPHY 

Urinate; at present she passes only small quantities of urine and 
urinated seldom. She has felt no pain or burmng on urination. 
She S no pain in the kidney region. She does not know 
whether the urine has contained blood. The vomitus has never 
contained blood or fecal matter to her knowledge.^ Her white 
count on admission was 9200; her temperature, 99-4 F 

She was in the hospital in December, 1911, and a diagnosis 
of tuberculous peritonitis was then made. She was put on 
tubercuHn treatment, with the usual hygienic and dietetic 
measures, and left the hospital in April, 1912, practically cured 
In 1908 she underwent an operation at which the left ovary and 
both tubes were removed. 

Her menstrual history is negative. There is no history of 
cancer in her family. Her father died of tuberculosis. ^ 

Pathology— An incision was made in the median line of the 
abdomen under nitrous oxid anesthesia. On opening the peri- 
toneum much blood was found in the abdominal cavity. On 
further explorarion a fibrous band was discovered which ex- 
tended from the site of the previous trouble in the pelvis upward, 
crossing the intestine, and strangulating the ileum. The ileo- 
cecal valve was located, and the ileum followed to the point of 
fixation by the band. The band was ligated at both ends and 
excised. The upper end was sutured with linen. There was 
no active tuberculosis found on careful examination of the 

abdomen. 

COMMENTS 

Dr. Murphy: Let us take the doctor's history and analyze 
it. The patient had first a sense of fulness in the epigastrium, 
accompanied by constipation. Three days later she had a 
sudden attack of cramp-like pains in the abdomen, at first most 
marked in the epigastrium, and then becoming rapidly gener- 
alized over the abdomen. Then she became nauseated and 
vomited. The primary nausea and vomiting in almost all of 
the acute abdominal conditions is a reflex affair, whether it is 
due to inflammation in an appendix or a gall-bladder, or whether 
It b caused by a renal calculus or an obstruction of the intes- 
tines. This primary reflex vomiting comes from irritation of the 



SURGICAL AND GENERAL DL\GNOSIS 619 

peritoneum. The vomiting in this case, however, differed from 
a simple reflex vomiting, such as we get at the onset of an 
appendicitis. With appendicitis the patients usually vomit once 
or twice, rarely a third time, and never continuously. But this 
patient kept right on vomiting until she was given morphin; 
then she began to vomit again just as soon as she came from 
under the influence of the morphin. This persistent, continued 
vomiting is strong evidence of the presence of an ileus. 

Before going further we must define what ileus is. The 
term does not signify a pathologic entity. It means a train of 
symptoms consisting of pain, nausea and vomiting, and failure 
of the bowel contents to move onward; that is, coprostasis. 

As soon as one grasps the fact that ileus is a S3mdrome and 
not a pathologic entity, then a good start has been made toward 
the clear comprehension of the differential diagnosis of the vari- 
ous pathologic conditions in the abdomen which give rise to that 
train of symptoms. 

When I saw the patient she was just getting over the effect 
of the morphin which her physician had administered to her at 
home. The abdomen was not much distended. The pain was 
returning and becoming more wavy and cramp-like. It appeared 
to be localized somewhat, first in the left hypochondrium, and 
finally in the left iliac fossa. The nausea returned and she 
began again to vomit. The vomitus was a distinctly offensive 
material, but was not of a fecal character. I have seen true fecal 
vomiting only twice in my life. It is a late symptom of ileus, 
and of grave prognostic import. If one waits to make the diag- 
nosis of ileus until the patient has fecal vomiting, one waits 
until the last few minutes before exitus. It is of very little help to 
us in making a diagnosis in time to save the patient. I do not in- 
clude it, therefore, among the symptoms in my ileus syndrome. 

Her temperature when she entered the hospital was 99.4° F. 
She probably had no fever preceding entrance to the hospital. 
She is well informed, the sister of a nurse, and states that al- 
though the temperature was repeatedly taken, no elevation was 
noted before coming here. The leukocyte count on entrance 
was 9200. She was given an enema shortly after admission and 
a bowel movement was obtained. One bowel movement, how- 



620 



CLINICS or JOHN B. MURPHY 



ever, does not rule out an intestinal obstruction. When I saw 
her she was just commencing to get the shrinking of the skin, 
and she was a Kttle cyanotic. The last lavage was not fecal, 
but it had a peculiar, offensive odor. She had no distinct ab- 
dominal distention. She was just beginning to have the wave- 
like, cramping pains which are so typical of the exaggerated 
Efforts of the intestine to overcome the obstruction. Her breath 
had the characteristic odor of intestinal contents which comes 
with ileus vomiting. One could smell it on entering the room. 
I have had placed on the board a classification of ileus and 
an outline of its symptoms. 



Diagnosis of Ileus 



I. History. 










(a) Previous. 


r (a) Mode of onset. 


(b) Present illness (b) Duration. 


[ (c) Present state. 


n. Symptoms. 




• I. Location. 






' I. Continuous. 


A. Pain 


2. Character • 


2. Spasmodic. 

3. Intermittent. 


. 


, 4. Duration. 


B. Tenderness '' ^^^^^«^- 

[ 2. Degree. 


C. Nausea. 




I. Time of onset. 




2. Frequency. 


D. Vomiting 


3. Persistenc} 

4. Gulping. 


1. Mucus. 

2. Bile. 




5. Vomitus ^ 


3. Intestinal contents 




4. Feces. 




5. Blood. 


E. Pulse 


I. 

2. 


Frequency. 
Quality. 







F. Temperature I '" P"™^^- 

^ (2. Secondary. 

G. Collapse j ^; Se"condary. 



SURGICAL AND GENERAL DL\GNOSIS 



621 



in. Physical signs. 

1. Face. 

2. Skin. 

3. Position. 

4. Tympanites 



Local. 
General. 

5. Irregularities of abdomen. 

f Position. 

6. Tumor \ Mobility. 

[ Resistance. 

7. Percussion. 
Local — irregular. 



(a) Dulness 



(6) Palpation 



General 

1. Resistance 

2. Induration 



changeable. 

Regular. 
Uniform. 



(c) Auscultation 



Shape. 
Surface. 
Sensitiveness. 

1. Increased peristalsis (local 
or general). 

2. Diminished peristalsis (local 
or general) . 

3. Absence of peristalsis (local 
or general). 

4. Induced peristalsis (local or 
general). 



Varieties of Ileus 
I. Adynamic (absence of peristalsis). 

1. Operations on mesentery. 

2. Prolonged strangulation. 

3. Spinal cord lesions. 

4. Afferent nerve lesions. 



5. Reflex 



6. Septic 



(a) Strangulated omentum. 

(b) Hepatic calculus. 

(c) Renal calculus. 

(d) Ovarian compression. 

(e) Pleuritic diaphragmatic 

pneumonia. 

(a) Local peritonitis. 

(b) General peritonitis. 

(c) Embolism. 

(d) Thrombosis. 



522 CLINICS OF JOHN B. MURPHY 

7. Uremia. 

8. Drugs (prolonged use). 
II. Dynamic. 

1. Lead poisoning (chrome). 

2. Tyrotoxicon poisoning. 

m. Mechanical (definite pathologic lesions). 

1. External (hernia). 

(a) Inguinal. 

(b) Femoral. 

(c) Umbilical. 

(d) Ventral. 

2. Internal. 

(a) Peritoneal pockets. 

(b) Diaphragmatic hernia. 

(c) Inguinal hernia. 

(d) Umbilical hernia. 

(e) Adhesive bands. 

(f) Diverticula. 

(g) Volvulus. 

(/r) Intussusception. 

,.v T., , I Internal. 

W Neoplasms I j,^^^^^^i 

(1) Cicatricial contraction. 
(k) Fecal impactions. 
(/) Foreign bodies. 

This classification does not agree with a number of the text- 
books in separating '' adynamic " and '' dynamic " groups. These 
two groups are included in many of the text-books in one, and 
should not be, because they are entirely different in type. 
*' Adynamic" means ** without power," and "dynamic," "with 
power. " I think it well to leave this classification just as we 
have it here. We have used it for many years in making this 
differential diagnosis, and it makes a fairly clear outline which 
can easily be kept in mind. 

Before taking up the consideration of the varieties of intes- 
tinal obstruction, let us recall some of the pertinent facts in the 
anatomy of the intestine. The gut, both large and small, is a 
potential tube, some 30 feet in length, provided with nerves, 
arteries, veins, and lymphatics. I say "potential tube," be- 
cause sometimes the lumen is open, containing Uquid or semi- 



SURGICAL AND GENERAL DIAGNOSIS 623 

solid matter or gas; at other times it is closed, and so tightly may 
it be closed by the contraction of its own muscularis that it may 
resemble a hard fibrous cord. The outer, or peritoneal, coat is 
a sensitive, tense, radiating membrane. Just inside of it Hes 
the firm but elastic muscular and fibrous layer. The inside coat 
is the mucosa. The mucosa, if spread out on a flat surface, 
would cover a much greater area than would the muscular layer 
or the peritoneum. It is thrown up in folds loosely attached 
to the muscularis, so that it readily accommodates itself to the 
varying tonus of the latter. 

As the intestinal contents keep moving from the inlet of this 
tube to its outlet, this forward motion is kept up by regular or 
irregular wave-Hke contractions of certain portions of the mus- 
cular coat of the gut, assisted by gravity and by the movements 
of the abdominal wall and diaphragm. If the contents fail to 
move forward and stasis occurs in the tube, various factors may 
be at fault. The muscular wall of the intestine may be relaxed 
or in a condition of atonic paralysis, because of an affection 
either of the muscle itself — as in thrombosis or peritonitis — or of 
its nerve-supply, as in spinal-cord lesions. On the other hand, 
the muscular wall of the intestine may be tensely contracted or 
in a condition of spastic paralysis, entirely obHterating the lumen 
and preventing any passage of contents. Such a condition oc- 
curs in lead and in tyrotoxicon poisoning. Then, again, the 
obstruction may be purely mechanical in nature, and located 
either entirely outside the alimentary tube, in its wall, or in its 
lumen. We shall cite instances later. 

Let us first consider adynamic ileus, the type due to atonic 
paralysis of the muscularis, and, in consequence, characterized 
by absence of peristalsis. Adynamic ileus may be caused by 
operations on the mesentery. If a portion of the mesentery 
more than i>^ or 2 inches in width at the intestinal margin is 
ligated, a dilatation of the segment of intestine supplied by it 
takes place as the result of the cutting-off of either the nerve- 
supply or the vascular supply, or both. Intestinal stasis imme- 
diately follows. 

Prolonged strangulation of a loop of gut is a lesion quite 



522 CLINICS OF JOHN B. MURPHY 

7. Uremia. 

8. Drugs (prolonged use). 
n. Dynamic. 

1. Lead poisoning (chrome; . 

2. Tyrotoxicon poisoning. 

m. Mechanical (definite pathologic lesions). 

1. External (hernia). 

(a) Inguinal. 
(6) Femoral. 
(c) UmbiUcal. 
{d) Ventral. 

2. Internal. 

(a) Peritoneal pockets. 

(b) Diaphragmatic hernia. 

(c) Inguinal hernia. 

(d) UmbiUcal hernia. 

(e) Adhesive bands. 

(f) Diverticula. 

(g) Volvulus. 

(h) Intussusception. 

,.v ,, , f Internal. 

(.) Neoplasms jj.^^^^^^1 

(i) Cicatricial contraction. 
(k) Fecal impactions. 
(/) Foreign bodies. 

This classification does not agree with a number of the text- 
books in separating ' * adynamic " and ' ' dynamic ' ' groups. These 
two groups are included in many of the text-books in one, and 
should not be, because they are entirely different in type. 
*' Adynamic" means ** without power," and "dynamic," "with 
power. " I think it well to leave this classification just as we 
have it here. We have used it for many years in making this 
diflerential diagnosis, and it makes a fairly clear outline which 
can easily be kept in mind. 

Before taking up the consideration of the varieties of intes- 
tinal obstruction, let us recall some of the pertinent facts in the 
anatomy of the intestine. The gut, both large and small, is a 
potential tube, some 30 feet in length, provided with nerves, 
arteries, veins, and lymphatics. I say "potential tube," be- 
cause sometimes the lumen is open, containing liquid or semi- 



SURGICAL AND GENERAL DIAGNOSIS 623 

solid matter or gas; at other times it is closed, and so tightly may- 
it be closed by the contraction of its own muscularis that it may 
resemble a hard fibrous cord. The outer, or peritoneal, coat is 
a sensitive, tense, radiating membrane. Just inside of it lies 
the firm but elastic muscular and fibrous layer. The inside coat 
is the mucosa. The mucosa, if spread out on a flat surface, 
would cover a much greater area than would the muscular layer 
or the peritoneum. It is thrown up in folds loosely attached 
to the muscularis, so that it readily accommodates itself to the 
varying tonus of the latter. 

As the intestinal contents keep moving from the inlet of this 
tube to its outlet, this forward motion is kept up by regular or 
irregular wave-like contractions of certain portions of the mus- 
cular coat of the gut, assisted by gravity and by the movements 
of the abdominal wall and diaphragm. If the contents fail to 
move forward and stasis occurs in the tube, various factors may 
be at fault. The muscular wall of the intestine may be relaxed 
or in a condition of atonic paralysis, because of an affection 
either of the muscle itself — as in thrombosis or peritonitis — or of 
its nerve-supply, as in spinal-cord lesions. On the other hand, 
the muscular wall of the intestine may be tensely contracted or 
in a condition of spastic paralysis, entirely obliterating the lumen 
and preventing any passage of contents. Such a condition oc- 
curs in lead and in tyrotoxicon poisoning. Then, again, the 
obstruction may be purely mechanical in nature, and located 
either entirely outside the alimentary tube, in its wall, or in its 
lumen. We shall cite instances later. 

Let us first consider adynamic ileus, the type due to atonic 
paralysis of the muscularis, and, in consequence, characterized 
by absence of peristalsis. Adynamic ileus may be caused by 
operations on the mesentery. If a portion of the mesentery 
more than lyi or 2 inches in width at the intestinal margin is 
ligated, a dilatation of the segment of intestine supplied by it 
takes place as the result of the cutting-off of either the nerve- 
supply or the vascular supply, or both. Intestinal stasis imme- 
diately follows. 

Prolonged strangulation of a loop of gut is a lesion quite 



624 



CLINICS OF JOHN B. MURPHY 



similar to ligation. The nervous and vascular supply is sim- 
ilarly compromised. If too long a period of time elapses be- 
tween the occurrence of strangulation and its correction by 
operation, the innervation of the gut may be so interfered with 
that peristalsis will not be restored. 

Lesions of the spinal^ cord produce atonic paralysis of the 
intestine by cutting off its central motor nerve supply. In 
fractures of the spine compressing the spinal cord high up in the 
dorsal region, the patient's intestine becomes immediately para- 
lyzed, and he develops great meteorism, not because he has lost 
control of his sphincter, but because the muscularis of his intes- 
tine is in a condition of atonic paralysis, like his legs. This con- 
dition will be permanent if the cord has been completely crushed, 
or will be followed by more or less recovery of tonus if the cord 
lesion is only partial. 

Mediastinal lesions involving the afferent nerves to the intes- 
tine, the vagus and sympathetic, may cause a suppression of 
peristalsis. I recall my first case of this class, a patient of the 
late Dr. Christian Fenger. Dr. Fenger, being called out of 
town, turned the case over to me to look after at the Cook County 
Hospital. The patient had an intestinal paralysis following a 
bullet wound just inside the mediastinum. The bullet passed 
under the clavicle in a downward and inward direction. When 
I saw him, on the sixth day after the wound was received, he had 
an enormous distention of the abdomen. When I percussed 
him as he was lying on his back, there was flatness in both flanks. 
I rolled him over to one side and the flatness traveled to that 
side; then I rolled him over to the other side, with the same 
result. Stethoscopic examination of the abdomen revealed no 
peristalsis anywhere. My diagnosis, therefore, was that the 
bullet had passed through the diaphragm, perforated his stom- 
ach, and produced a perforative peritonitis, with much free fluid 
in the peritoneal cavity. I performed a laparotomy, and on 
opening the abdomen found nothing there but intestines. And 
it was full of them. The coils were of enormous size, with entire 
absence of peristalsis. The movable flatness on change of 
position was due solely to movement of the liquid contents of 



SURGICAL AND GENERAL DLAGNGSIS 625 

these greatly dilated loops of gut. Something in the operation 
started up peristalsis, his bowels began to move freely, and he 
got well, in spite of the operation, without any further trouble. 
That I have always considered a typical case of atonic paralysis 
of the intestinal muscularis from interruption of its nerve- 
supply in the mediastinum. 

In the production of reflex paralysis of the intestine the 
mechanism is not so clearly apparent as in the preceding class of 
cases. In a case of strangulation of the omentum the symptoms 
develop, as in the case which we have just been discussing: Pain, 
nausea and vomiting, local sensitiveness, absence of fever, and, 
if sufficient time has elapsed, coprostasis. If the cause of the 
reflex paralysis, the strangulated omentum, is not removed, the 
paralysis continues until such time as the omentum becomes 
necrotic and, in consequence, ceases to give peritoneal or other 
reflexes. This is the kind of case that responded to medical 
treatment in the preoperative era. The same statement holds 
true for reflex paralysis due to biliary calculus, renal calculus, 
strangulation, ovarian compression, twisted pedicles, and the Hke. 

Diaphragmatic pleurisy is one of the rocks on which many 
abdominal diagnoses are wrecked. Both the "simon-pure'* 
surgeon, who leaves internal diagnosis to "the other fellow," 
and the "operating gynecologist" meet here their due reward. 
Their diagnosis is, uniformly, first, appendicitis, and, second, 
intestinal obstruction. Why? Because there is a paralysis of 
peristalsis, and if the pleurisy is on the right side, a tender 
point over the lower abdomen; and when the palpating hand is 
applied, the abdomen is felt to be tense. Why? Because the 
abdominal muscles, by contracting, are trying to limit the ex- 
cursions of the affected side of the diaphragm and ease the pain. 
The piston of respiration is the diaphragm, and its every stroke 
is painful in pleurisy. The patient cannot stop this engine alto- 
gether, but his abdominal muscles can slow it by putting the 
brake on the transmission. Pleurisy, however, can always be 
differentiated from ileus of the mechanical type by the presence 
of fever. In the acute stage of a mechanical obstruction there 
is never an elevation of temperature. I recall a case, not a 
VOL. in — 40 



526 CLINICS OF JOHN B. MURPHY 

hundred miles from here, a four-year-old f^J^^''/'^^^ 
phoned me that she had acute intestmal obstruction of some 
iiree days' duration. The doctor said her temperature was 
io^° F I repUed at once that this could not be an acute mtes- 
tiiil obstruction-that it was more likely an appendicitis. 
When I went out I expected to operate for an appendicitis. The 
patient had an enormous distention of the abdomen. After 
examining her I did not operate. I gave her a hypodermic in- 
jection of morphin, and in a few hours her bowels began to 
move copiously. She had a diaphragmatic pleurisy. In that 
particular case I treated the obstruction with morphin. Why? 
Because the obstruction was a reflex phenomenon from^ her 
pleurisy. When the morphin eased the pain, the inhibiting 
effect of the latter on defecation was removed. That is what 
morphin does in all these cases. It is not a discovery of mine. 
Dr. James Allen taught us that. The way he stated the rule 
was: "When, in an intestinal obstruction, the bowels do not 
move with a cathartic, give morphin." He knew from cUnical 
experience that one class of cases was relieved by morphin and 
the other class made worse; but he did not know which was 
which until he made the test. That is the difference in diag- 
nostic acuity between his time and ours. 

Of the next group of cases, the septic adynamic ileus, which 
for a long time it was so difficult to differentiate, the most com- 
mon variety is that due to a local peritonitis. The patient, for 
instance, has primarily an acute appendicitis with perforation, 
or an infection from above, such as a perforation of a duodenal 
or gastric ulcer or an acute perforative cholecystitis. That 
patient develops at once a suspension of peristalsis and inability 
to secure a bowel movement. Then what? The temperature 
begins to rise and the leukocytosis begins to shoot up. In all 
the cases of this type in which a general peritonitis develops the 
peristalsb completely ceases, usually until death. A patient 
presents the symptoms and history of an attack of acute appen- 
dicitis, for instance, of three or four days' duration. When the 
doctor sees him the bowel action may have been suspended for 
twenty-four or forty-eight hours. The patient probably vomited 



SURGICAL AND GENERAL DIAGNOSIS 627 

at the onset of the trouble, and now he commences to vomit 
again. You give him enemas, but the patient does not get a 
bowel movement until, perhaps, an hour before death, and then 
such a patient has an expression of intense suffering, cyanosis, a 
shrunken skin, and contraction of the hands. When one sees 
that syndrome one knows that within a few hours the patient 
will be dead. That is what ad3mamic ileus from general septic 
peritonitis is like. There is only one sure way to ciure it — ^take 
out the appendix before the peritonitis has developed. The 
man who has had to manage such a case needs no further argu- 
ment for the early operation in appendicitis. 

EmboHsm and thrombosis also produce a paralysis of the 
bowel. Embolism of the superior mesenteric artery takes place 
suddenly, and its symptoms develop with like rapidity. It may 
be easy to recognize, but often, perhaps usually, it is overlooked, 
particularly if the patient is already ill from his primary affec- 
tion — the source of the embolus. Let me cite a case: The 
patient had an acute recurrence of a mitral endocarditis. He 
was in bed for seven weeks. He finally went home from the 
hospital when the acute symptoms had subsided. He was prac- 
tically well, with a pulse ranging from 80 to 90, a normal tem- 
perature and a normal white count, and a moderate secondary 
anemia. He had been home for four or five days, when one 
night he suddenly called his nurse and said to her: "Something 
has happened; I have just had a severe pain in my abdomen." 
The nurse took his pulse and found it running along at the rate 
of 140 per minute. His doctor, when he came in the morning, 
examined the patient and noticed that the abdomen was sensi- 
tive on the right side. The patient then had pain, nausea, and 
vomiting, but no elevation of temperature. Nevertheless, the 
doctor made a diagnosis of appendicitis. Now, an appendicitis, 
never begins with a pulse-rate of 140 in the first five, six, or seven 
minutes of the onset. In perforative peritonitis, even, it takes 
time for the symptoms to develop, particularly the rapid pulse. 
The doctor called another physician in consultation, and it was 
decided to operate for the appendicitis. He telephoned me, and 
in my conversation over the phone I said, "You remember that 



628 



CLINICS OF JOHN B. MURPHY 



man had a liver embolus during his recent attack of endocarditis. 
I think you ought to consider the possibiHty of an embolus of 
the mesenteric artery, because the pain and the sudden increase 
in his pulse-rate would speak for an embolus." However, the 
doctor insisted on operating. The abdomen was opened and the 
entire intestinal tract suppUed by the superior mesenteric artery 
was found gangrenous from an embolus. The abdomen was 
dosed and the patient died. I cite that case to demonstrate that 
such suddenness of onset and such rapid increase in pulse-rate 
put appendicitis out of consideration. 

The embolus, if large, when it passes through the heart, pro- 
duces a feeling of impending death. I saw, years ago, many 
cases of thrombosis with embolism after parturition. The 
patient would apparently be making an uneventful recovery, 
when suddenly she would send for the doctor, saying, "I am 
going to die! I am going to die!" because of the feeling of con- 
striction in the chest as the embolus passed through the heart 
to be arrested in the pulmonary artery. This sensation of im- 
pending death is highly typical of a large embolus passing through 
the heart. 

Thrombosis of the portal vein is a much more difficult condi- 
tion to diagnose and has a slower onset. The patient with this 
lesion has pain in the abdomen, then nausea, and occasionally 
vomiting. There is usually some elevation of temperature and 
the spleen becomes palpable. Many of you may remember Dr. 
Wright, of Carroll, Iowa. He went to Europe in the summer of 
1913. In Paris he did not feel very well, and separated from his 
two American colleagues one day, saying he would rejoin them 
after forty-eight hours' rest. The abdominal pain of which he 
had been complaining grew more severe, his abdomen became a 
little more sensitive, and then still more so. His two friends 
came to see him, examined him, and decided that a laparotomy 
was advisable. He had previously had an appendectomy per- 
formed, so that they knew that this could not be an appendicitis 
attack. The next day they opened his abdomen and found a 
thrombosis of the superior mesenteric vein with a wet gangrene 
of all the intestine drained by the vessel. They closed the abdo- 



SURGICAL AND GENERAL DIAGNOSIS 629 

men, and Dr. Wright joined the great majority. The diagnosis 
of thrombosis is often difficult, but one can usually come to the 
conclusion that there is a lesion present requiring surgical inter- 
ference. The symptoms are abdominal, and they go from bad 
to worse. The operation makes the diagnosis, but does nothing 
more. Unfortunately, these cases never recover. Such a 
thrombosis may occur in the mesenteric vein, the internal iliac, 
the portal, and the pulmonary artery. 

Pericholecystitis is another cause of adynamic ileus. Uremia 
is another. I remember one of my earliest cases of this condition 
where I made the mistaken diagnosis of intestinal obstruction, 
because of the headache, persistent vomiting, and obstipation. 
These patients have headache, nausea and vomiting, intense 
abdominal pain, and often fever. If one opens the abdomen in 
such a case, as I have done, he will be surprised to find no me- 
chanical obstruction, perhaps no obvious lesion in the abdomen at 
all. If the patient survives the anesthetic and operation and you 
examine him further, you will find albumin and- casts in the 
urine. This is a condition which is overlooked not uncommonly. 

That concludes the common classes of adynamic ileus which 
are characterized by an absence of audible or visible peristalsis. 
In these cases it is usually impossible to elicit bowel movements 
by any of the ordinary simple measures. 

Dynamic ileus includes lead poisoning and tyrotoxicon poi- 
soning. I well remember a case I operated at Alexian Brothers' 
Hospital, the patient of Dr. Hoelscher. He had made the diag- 
nosis of lead colic, and was treating the patient on that basis. I 
was called in consultation on the sixth day of the disease. The 
patient had not had a bowel movement from the onset of his 
trouble up to this time. My opinion was that there must be 
something more than lead colic present to make this persistent 
inability to secure a bowel movement, and the vomiting, contiYiue. 
We accordingly opened the abdomen. On searching for the 
obstruction we found a portion of small intestine, 12 or 15 inches 
in length, so slender, white, and hard that it looked like a cicatri- 
cial band. It felt brittle and unyielding enough to break. I 
exclaimed, ''There it is! I told you so. That is something more 



530 CLINICS OF JOHN B. MURPHY 

serious than lead coUc. " Then I examined it and found that it 
was only intestine, contracted and spastic, but continuous at 
both ends with loops of small gut. That fact told me unmis- 
takably that I was dealing with the tonic intestmal contraction of 
a lead colic. I explored the abdomen further, but could find no 
other lesion. We brought up the bowel preparatory to resection, 
and wrapped it in a warm towel; but m the few minutes occupied 
in preparing for resection the bowel expanded to its full size; 
of course, we did not resect, but administered morphin hypo- 
dermatically, and the patient made a good recovery. That was 
the only time I have ever seen the bowel in the contraction of a 

lead colic. 

It is tyrotoxicon poisoning which causes the obstinate cop- 
rostasis with milk-, and occasionally with ice-cream-, poisoning. 
Dr. Hibbard, a very promising young man of this city, died of 
milk-poisoning, the prominent symptom of which was a com- 
plete absence of peristalsis, like that of an intestinal obstruction. 
The reports of these cases in the literature tell of a tonic contrac- 
tion of the intestine, white and hard, like cicatricial tissue, as in 
•nfy case of lead colic, for these cases, like my case of lead colic, 
are sometimes operated under the erroneous diagnosis of me- 
chanical obstruction of the intestine. 

The mechanical obstructions are the group which we shall 
next consider. The cases of mechanical ileus practically all 
have symptoms much like those of the case we have just consid- 
ered. Most of them are easily recognizable. The difficult cases 
of ileus to diagnose are those in class 5, the cases of reflex ileus. 
These patients with mechanical ileus do not have fever; peris- 
talsb is present and usually audible, but the abdomen is rigid. 
This abdominal spasticity is a more important sign in the early 
stage of mechanical ileus than it is in the later stage — much more 
important. 

The conditions which most frequently produce mechanical 
obstruction of the bowel are, strangely enough, conditions situ- 
ated external to the abdomen proper, namely, the external 
hernias. The varieties are: Inguinal, femoral, umbilical, 
and ventral hernia, the inguinal hernia being by all odds the 



SURGICAL AND GENERAL DIAGNOSIS 63 1 

most common. Femoral hernia is more commonly the cause of 
intestinal obstruction in women, however, than is inguinal 
hernia. When a loop of the intestine slips into one of these 
peritoneal pockets, the intestinal contents are no longer able to 
move forward, because of the compression and kinking of the 
bowel, just as the water in a hose no longer can run when the 
hose is kinked. In incarceration of a loop of gut in a hernial 
pocket there are two pathologic processes at work, each pro- 
ducing its train of symptoms. The stoppage of the forward flow 
of feces produces the symptoms of intestinal obstruction, which 
we have already described at some length. If the circulation in 
the intestine is shut off at the same time, the symptoms of 
strangulation are added to those of ileus. One must never con- 
found these two conditions. A mechanical obstruction of the 
bowel which merely prevents the onward movement of the fecal 
current may last for many days before the patient succumbs, 
particularly if the obstruction is located low down in the track. 
A strangulation ileus which has existed for forty-eight hours kills 
the patient nearly always, operation or no operation. If oper- 
ated, the patient dies rid of the obstruction, but not of its 
sequences, such as gangrene of the intestine, perforative peri- 
tonitis, paralysis of the intestine, dilatation and ulceration of 
the bowel above the obstruction, toxic absorption, loss of fluids 
by vomiting, operative shock, etc. Therefore it is vitally im- 
portant to keep strangulation ileus sharply separated from 
obturation ileus. Further, one finds sometimes, after reducing 
a hernia suspected of being strangulated, that the vomiting does 
not subside in two or three hours after the reduction, but rather 
seems to increase in severity. Then one knows that, although 
the hernial protrusion has been reduced, the obstruction has not 
been relieved, and an immediate laparotomy must be performed 
in order to save the patient. The continuance of the symptoms 
of ileus after hernial reduction means usually that the constricting 
band, or whatever else is causing the obstruction, has not been 
dislodged by the reduction. 

An umbilical hernia is a constant source of danger to its 
owner from intestinal obstruction, because the pockets or diver- 



5^2 CLINICS OF JOHN B. MURPHY 

ticula, which it so often contains, offer a perennial invitation to 
the neighboring loops of gut to enter and become strangulated, 
and in this variety of hernia the reduction en masse especially 
frequently fails to relieve the obstruction. 

A femoral hernia may or may not emerge from the femoral 
canal. The serious feature in femoral hernia is its inelastic wall, 
formed by Gimbemat's and Poupart's ligaments. If a knuckle 
of bowel becomes incarcerated in this rigid canal, the pressure 
of these unyielding ligaments easily produces a pressure necrosis.. 
The combination of early pressure necrosis of the bowel with 
strangulation of the intestinal circulation and obturation ileus 
constitutes a highly fatal triad in femoral hernia. The pr oneness 
of this deadly triad to occur in an incarcerated femoral hernia 
makes it necessary to operate on these cases at the earliest 
possible moment, that is, at an earlier date than in the case of an 
incarcerated inguinal or even of an umbilical hernia; otherwise 
the operator and patient face serious consequences. If the 
patient is delayed in coming to operation, one must expose the 
incarcerated intestine with great care, because, in making trac- 
tion on it, one pulls the bowel directly against the unyielding 
ligaments of Gimbemat and Poupart, and can very easily rupture 
a friable, partly necrotic loop of bowel and flood the peritoneal 
cavity with the highly toxic and infectious contents of the in- 
testine above the obstruction. In inguinal hernia strangulation 
is not so common nor is it fraught with such imminent perils as 
in the femoral type. 

The results in this field of abdominal surgery have not 
materially improved in thirty years, even with all the great 
recent increases in our knowledge of the pathogenesis and 
symptomatology of disease, and with all the modem improve- 
ments in surgical technic. The mortality, too, in mechanical 
strangulation of the bowel has not materially changed during 
these thirty years. Why? Because the diagnosis of mechanical 
ileus is sUll too often not made m time; and, even when it is 
properly made in due season, prompt surgical action is not per- 
mitted by the people, or is not demanded vigorously enough by 
the physician. The physician who waits before insisting on a 



SURGICAL AND GENERAL DIAGNOSIS 633 

laparotomy until he sees that his patient will die of the obstruc- 
tion unless operated, will find out to his sorrow that his patient 
will also die after he has been operated 

If the incarcerated coil of bowel be large, obstruction can 
continue some little time without terminating fatally, because 
strangulation and necrosis occur much less readily in a large loop 
of bowel than in a small knuckle of it. If a mechanical ileus due 
to strangulation of the bowel has existed for from twenty-four 
to thirty hours, and at the operation the obstruction is relieved 
but the strangulated bowel not resected, considerable time will 
have been saved by the operator, but the patient's life may be 
the forfeit. 

In so long-standing a strangulation the nerve-supply of the 
bowel is usually compromised, even though the blocking of the 
intestine's vascular supply has not been sufficient to produce 
necrosis of the loop. The result is that after the mechanical 
obstruction has been relieved, a paralytic (adynamic) ileus super- 
venes, which usually is fatal. The only outlook for a successful 
solution of this professional dilemma consists in training our 
practitioners to make accurately the differential diagnosis be- 
tween the mechanical type and the other types of ileus, to make 
the diagnosis early, and to act on the diagnosis with the prompt- 
ness and positiveness of a deep-rooted conviction, based, if not 
on an adequate experience of his own, at least on a first-hand 
knowledge of the experience of others. 

We have been discussing mechanical ileus of external origin. 
We now have to consider the internal sites where strangulation 
of the bowel may occur. Peritoneal pockets, either congenital 
or acquired, are a fruitful source of mechanical ileus. The 
congenital or anatomic peritoneal pockets occurring in connec- 
tion with the external hernial openings are found most frequently 
in relation to the inguinal tract; perhaps the next most frequent 
location for them is in the neighborhood of the cecum. Peri- 
toneal pockets also are found near the duodenojejunal junction, 
and into them the so-called hernias of Treitz occur. Still other 
pockets, those of Waldeyer and Broesike, are found occasionally 
in the mesentery near the beginning of the jejunum. These are 



534 CLINICS OF JOHN B. MURPHY 

the positions where the anatomic peritoneal pockets most fre- 
quently occur. Hernia into pockets other than these, such as 
into the foramen of Winslow or into intersigmoid or retrovesical 
pockets, is relatively rare. 

In the inguinal tract the pocket of peritoneum most fre- 
quently runs beneath or along the inner side of the canal. I 
shall not consider the pathology and management of these in- 
ternal hernias in detail, but I should like to record here a case of 
intersigmoid retroperitoneal hernia which I operated on, par- 
ticularly inasmuch as Moynihan states that there are only two 
others recorded in the entire literature of hernia. The pocket in 
this case lay retroperitoneally, behind the sigmoid. The in- 
testines had passed into and become strangulated in this pocket 
in both cases. The patient presented signs of strangulation of 
the bowel, but without any external manifestations of hernia. 
I well recall the case. I was called to see him in a home in one 
of Chicago's poorer districts. The man called me because of a 
severe pain in the abdomen, sudden in onset, followed by vomit- 
ing and obstipation, but not by fever. Examination of the 
inguinal tracts and other hernial openings revealed nothing 
abnormal; but on both percussion and palpation of the abdomen 
he evinced considerable sensitiveness in the left lower quadrant. 
If these findings had been on the right side of the abdomen, we 
should have considered the case possibly an afebrile appendi- 
citis, such as we sometimes see when the ulcerated appendix is 
draining freely mto the cecum. We took this patient to the 
hospital, performed a laparotomy, and discovered that a coil of 
the intestine had passed into a subperitoneal pocket at the root 
of the sigmoid, and had become twisted on itself inside the pocket 
to the extent of producing a strangulation. The bowel was 
disengaged from the pocket, the volvulus straightened, and the 
patient made an uneventful recovery. 

In the case of hernia into an inguinal pocket which I remem- 
ber best there was also strangulation of the incarcerated coil of 
intestme. I operated in the dark! The man who was holding 
the kerosene lamp for me fainted and fell on the floor with the 
lamp while we were operating. The only medical assistant I 



SURGICAL AND GENERAL DIAGNOSIS 635 

had with me, an ex-street-car conductor, who had just graduated 
from the two-year medical course of one of our Chicago schools, 
was giving the anesthetic and I could not spare him from that 
duty, because the patient was in such a critical condition. A 
clergyman, called to assist at a demise, stayed to officiate in 
a revival. He was holding retractors for me, but continually 
begged to be let off because the sight and smell of blood were 
sickening to him. I couldn't spare him and therefore, grimly 
kept him on the job. We finally found the coil, however, 
split the pocket, and, after removing and straightening out the 
bowel, sewed up the pocket. The patient recovered in spite of 
these vicissitudes. 

I could relate many cases of retroperitoneal hernias in the 
various other positions. Unless one bears them in mind when 
operating, and imless one knows their anatomic relations, one is 
very likely to overlook them. There is one variety which it 
is especially easy to overlook — the duodenojejunal hernia — ^be- 
cause the obstruction is in the upper portion of the jejunum, which 
has passed into the sac and lies hidden retroperitoneally. Practi- 
cally all the visible bowel is seen to be collapsed on opening the 
abdomen. Usually no distended coil is to be seen. As one 
follows up the collapsed ileum and the jejunum, one may finally 
come, just at the duodenojejunal flexure, to a single short coil of 
distended bowel, not continuous with the jejunum, which has just 
been passing through one's hands. This is the most dangerous 
location for such a retroperitoneal hernia, because the visible 
loop of distended bowel may be not more than two or three 
inches in length and is easily overlooked. Many is the case 
where this strangulated bowel is not found by the surgeon, the 
patient continues to vomit until he dies, and only at the autopsy 
is the coil discovered. The surgeon's troubles are not all over 
in these cases even when the seat of the obstruction is located, 
because in freeing the jejimum from the sac and returning it to 
the peritoneal cavity the superior mesenteric vessels stand in 
grave danger of injury . 

Another, often puzzling, variety of internal hernia is that 
through the diaphragm. Diaphragmatic hernias are often diffi- 



536 CLINICS OF JOHN B. MURPHY 

cult of diagnosis. They occur commonly following trauma, but 
occasionally are congenital. There may be a separation of the 
crura of the diaphragm. The case of diaphragmatic hernia 
which I remember most particularly, because it was my first, 
occurred one Sunday many years ago. The patient, a brake- 
man, in jumping from the top of a freight car, felt a sudden pain 
in his left side. When he reached home the pain was worse, he 
became nauseated, and began to vomit. Then he called me. I 
made a diagnosis of ileus. I brought him to the hospital and 
opened his abdomen. The intestines were systematically ex- 
amined, but nothing was foimd until, finally, when we came to 
pull out the splenic flexure of the colon, the splenic flexure refused 
to budge. At last, in trying to grub it out, we followed the colon 
up under the diaphragm and found the coil of splenic flexure 
inside the pleural cavity. It had been in there already for a 
number of hours. The coil was not necrotic, so we sewed up the 
hole in the diaphragm without resecting any bowel; but the 
patient died after the operation, just as so many of these ileus 
cases die, from the intoxication due to the obstruction, and 
without an elevation of temperature at any time. 

Umbilical hernias are another fruitful source of intestinal 
strangulation. Although they are often small, they may, even 
then, catch a portion of the wall of the intestine and cut off its 
vascular supply. Such a case may occasionally develop merely 
a fecal fistula and recover instead of terminating fatally from 
perforative peritonitis. 

Adhesive bands are common in the abdomen; particularly 
frequent are those which develop from remnants of the vitello- 
intc^tinal duct, usually about 39 inches from the ileocecal valve. 
In that location small folds are of frequent occurrence. One of 
them becomes fixed to a portion of intestine and then another 
coil slips underneath this band and becomes strangulated. One 
is apt to have difficulty in getting the coil out of this trap unless 
one follows a definite line of procedure as a routine in these cases. 
Such a knuckle of bowel necrotizes early— almost as early, in 
fact, as necrosis of the intestine occurs in an incarcerated femoral 
hernia. 



SURGICAL AND GENERAL DLVGNOSIS 637 

Diverticula, particularly Meckel's, we shall dismiss with a 
word. When they form adhesions, they act like bands in pro- 
ducing strangulation. 

Volvulus may involve the large or the small intestine. It is 
more common in the former. I remember well one case I saw. 
The woman had a pain like a colic, but no elevation of tempera- 
ture. When I saw her, after several consultations had already 
been held, she had a mass in her abdomen which was as large as 
a fourteen months' fetus, if you can imagine what that would be. 
The abdomen was enormously distended. There was con- 
siderable visible and audible peristalsis, and the patient's skin 
was already cyanotic. I made a diagnosis of obstruction of the 
large bowel. At operation we found a volvulus involving prac- 
tically all the large intestine. The cecum and colon above the 
obstruction had attained a diameter as great as a child's thigh. 
When it was brought out of the abdomen it exploded, making a 
noise like the bursting of an inflated paper bag. We had to 
resect all the large intestine. The patient died some forty- 
eight hours after the operation. When the symptoms are as 
clear-cut as they were in this case, there is no occasion for wait- 
ing to operate until the intestine is gangrenous. Delay was the 
error of omission in this case, and it cost the patient her life. 
That is the reason why I am citing the case — to call your atten- 
tion to the imperative need for early diagnosis and prompt action 
in cases of mechanical ileus. 

Intussusception is commonly a lesion of infancy, but occurs 
also in adults, tumors, particularly polypi, often furnishing the 
stimulus for its origin. Its presence is very frequently overlooked, 
and yet it has a characteristic set of symptoms which can scarcely 
be mistaken by the experienced clinician for any other condition. 
For instance: A child is eating or playing, apparently as well as 
usual, when suddenly it screams out with pain. It at once lies 
down, no matter whether it was standing or sitting previously. 
The onset may be almost like a shot in its suddenness. The 
mother tells you the story in this way: "Why, she was sitting 
there perfectly well. Suddenly she screamed and turned white; 
then she made an effort at vomiting. Since then her bowels 



538 CLINICS OF JOHN B. MURPHY 

have not moved. " That may be hours before blood appears in 
the feces, and still longer before the bowel commences to protrude 
from the anus. The onset is so uniformly typical— so classic 
usually, that one has only to think of the condition to make the 
diagnosis in an instant from the history alone. Then one verifies 
the diagnosis, after removing the child's clothing, by palpating a 
kidney-like mass in the abdomen, usually in the right iliac fossa. 
Often, however, the mass does not lie so low. It may be in the 
right upper quadrant, in the epigastrimn, or even on the left side 
of the abdomen. The ileocecal region is the common seat of an 
intussusception, both in the child and adult. When it occurs in 
the adult, its onset is just as sudden as in the child; but, sub- 
sequently, there appear recurrent pains in the adult. The child 
becomes indifferent to these recurrent pains, and lies limp and 
uncomplaining in bed; but the adult finds these cramps a cause 
for serious complaint. What makes the pain so severe? The 
obstruction? No, It is the constant pulling of the waves of 
peristalsis downward on the intussusceptum. To show you how 
strong such an intestinal pull is and how painful it may become 
I will cite an instance, a case of a different class. We have a 
little girl in the hospital now with a cicatricial obstruction of the 
esophagus. In order to dilate the stricture safely we first had 
her swallow some silk thread. The thread coiled up in the 
esophagus for a time, but finally a strand of it passed through 
the tiny esophageal opening into the stomach. Everything went 
very well umtil the thread passed down through the intestine and 
came out the anus. Then the pulling of peristalsis started in in 
earnest. At first we could control the discomfort by feeding in 
the thread constantly, but finally that artifice did not suffice. 
The pain from the pulling of the intestine on the thread became 
intolerable. One would scarcely think that so slippery a struc- 
ture as the mucous membrane of the intestine could grip a smooth 
silk thread with enough finnness and strength to produce a pull 
which could cause such pain. The pain was so severe, finally, 
that we had to cut the thread at its buccal end, allow it all to 
pass through the bowel, and then start again by passing a fresh 



SURGICAL AND GENERAL DLA.GNOSIS 639 

thread. Every week or two we had to start a fresh thread, as 
long as it was necessary to have a guide for our dilators. 

Imagine the severe pain produced when so large a structure 
as a coil of intestine starts to travel like the string! This severe 
pain occurs in intussusception long before blood appears in the 
feces, and still longer before there is any protrusion of the bowel 
at the anus. That brings us back again to the subject of the 
prime importance: the patient's story in diagnosis. The story 
makes the diagnosis of intussusception far better than any other 
single element in the case. These patients finally show some 
elevation of temperature, and then, usually, the coprostasis and 
the rapid pulse become marked. 

Neoplasms of the intestines produce mechanical ileus. That 
is one of the things we thought of in the case this morning (Mrs. 
A). (See the case of "Paralytic Ileus from Cryptogenic Peri- 
tonitis" elsewhere in this issue (p. 719) of the Clinics.) Bait the 
story of the case is wrong for a cancer in the bowel. The sudden 
pain in the left iliac fossa which she had in December, 19 13, and 
the vomiting and fever, then recovery and then recurrence of the 
sudden pain, a temperature of 103° F., and a leukocyte count 
of 51,000 all speak strongly against cancer as the cause of the 
obstruction. Such a story might be possible with a lesion in the 
sigmoid, such as a parasigmoidal sinus, which may set up an 
inflammation in the left side of the abdomen, resembling very 
much the inflammation which appendicitis produces on the right 
side, accompanied by local pain, elevation of temperature, and 
an inflammatory adynamic ileus — not a mechanical obstruction. 
Her vomiting subsided entirely before she came to operation. 
The vomiting in both the dynamic and adynamic types of ileus 
diminishes as time passes, because here it is only a reflex condi- 
tion. The vomiting in mechanical ileus, on the other hand, in- 
creases as time passes, because there is an obstruction to the 
outflow of the intestinal contents which, accordingly, overflow 
in the reverse direction. The vomiting of a mechanical ileus is 
a regurgitation, not a reflex peristalsis. An elastic tube, whether 
it be 30 feet or 30 inches in length, is elastic only to a certain 
degree. Beyond its elastic limit it is inelastic. If you close it 



540 CLINICS OF JOHN B. MURPHY 

at one end, its contents must escape at the other end. The 
bowel cannot stretch beyond its elastic hmit, and must, there- 
fore, sooner or later overflow. That is an important point to 
remember about the vomiting in a mechanical obstruction. It 
is an overflow; and, as the quantity of intestinal contents in- 
creases from the gastric, biliary, and hepatic secretions and from 
the succus entericus, the overflow becomes greater and greater. 
The passive congestion usually present and due chiefly to pres- 
sure on the veins in the compressed mesentery adds greatly to 
the flow of succus entericus. 

Fecal impaction is one of the very rare causes of ileus, par- 
ticularly in private practice. I do not remember having seen 
three cases of fecal impaction producing an ileus in my whole 
experience. In insane asylums, however, fecal impaction is by 
no means an infrequent cause of obturation ileus, particularly 
in negativistic patients, such as catatonics and some senile de- 
ments. The symptoms, however, are usually mild, and the diag- 
nosis rather easily made by feeling the hard scybala through the 
abdominal wall or in the rectum. Enteroliths and foreign bodies 
are more frequently the cause of obstruction. An enterolith 
consists of the fecal material which forms and dries in an in- 
testinal pocket, particularly in the large bowel, becomes extruded 
finally into the intestine, and then moves along with the fecal 
current, becomes stationary, and then moves again. If small, 
it will pass out the anus, and if large, it may become impacted 
along its course and produce obstruction. A large gall-stone 
acts similarly. A gall-stone may ulcerate through the gall- 
bladder and into the small or large intestine, and likewise become 
impacted as a foreign body in the bowel. It may move along 
for a while, become stationary, start moving again, get into a 
diverticulum in the bowel, and become stationary for a longer 
period. Every time it moves the patient has colic. When it 
becomes stationary, whether it is a gall-stone in the intestine or 
in the biliary tract, whether it is a fecal concretion or a renal cal- 
culus in the ureter or urethra, the moment it becomes stationary 
the pain ceases. I recall one enterolith which I removed by 
operation twenty years after its formation. The patient had 



SURGICAL AND GENERAL DLA.GNOSIS 64 1 

eaten plum pudding in particularly excessive quantity once when 
he was a boy, and the soggy mass became impacted then in his 
stomach. It finally passed from the stomach into the intestine. 
Every time it moved from one pocket to another he had severe, 
cramp-like pain. In the course of twenty years it finally reached 
the narrowest portion of the small intestine, which lies about 
three inches above the ileocecal valve, and pressure due to the 
obstruction then became so great that it started to produce 
gangrene of the bowel. Then the concretion had to be removed. 
It was as large as a crab-apple. Perhaps the chief lesson which 
that case teaches is the great efiiciency of the protective mechan- 
ism of the bowel in preventing a foreign body in the intestine 
from producing continued obstruction. A diverticulum forms 
about the enterolith, just as it does about a stone in the cystic 
or common duct or about a renal calculus in the ureter, the fecal 
material passes by, and the trouble is over until something starts 
the concretion again on its travels. Then we have a return of 
the coKc — because colic means motion or progress of the foreign 
body. 

I remember that when I was beginning the study of surgery 
intestinal obstruction was a great topic for discussion, first, as 
to its differential diagnosis, and, second, as to whether the re- 
sults obtained by operating were better than by not operating. 
Indeed, you will find in the older literature a splendid array of 
statistics, showing that patients with intestinal obstruction re- 
covered without operation equally well if not better than with 
operation. [See Dr. Murphy's original article on '' Intestinal 
Anastomosis by Use of the Button, " in the Medical Record, 1892.] 
Why? Because the surgeons then had not learned, nor have 
we all learned today, sharply to differentiate between the mechan- 
ical type and the adynamic and dynamic types of ileus. The 
cases in the last two groups often get well without operation — 
the cases of the mechanical type die unless surgical intervention 
is prompt. We had to learn to differentiate between the paraly- 
sis of peristalsis which is associated with a general peritonitis, 
for instance, and that which is due to a volvulus or strangulation 
of the bowel. One can see that there is a good reason why a 

VOL. Ill — 41 



5-2 CLINICS OF JOHN B. MURPHY 

larger number of the cases of intestinal obstruction used to get 
well without operation than with, because the majority, by aU 
odds of ileus cases are those of the adynamic and dynamic types, 
the CTeater part of which get weU, as a rule, without any surgical 
interference with the intestine. If you will keep this funda- 
mental difference between the two classes clearly in mmd and 
learn to associate the symptoms of ileus with the physical signs, 
you will soon be able to determine which case needs an operation 
for intestinal obstruction and which does not. But if you are 
not able to make this differentiation in clean-cut, typical cases, 
you certainly will be at a loss in border-line cases to say which 
patient needs surgical intervention to determine the nature of 
the case, as well as to treat it, and which other does not. 

Let me give an illustration. Take, for instance, a case of 
septic ad>'namic ileus. Septic adynamic ileus is many times 
present with a local peritonitis and always present with a general 
peritonitis. Why? Because the peristalsis is stopped by the 
action of the infection of the surface of the bowel on the intestinal 
muscularis. There is no abdominal sound to be heard in these 
cases except the splashing of the fluid in the dilated bowel on 
change of position of the patient, or when the diaphragm con- 
tracts in respiration or in singultus. I will cite the history of a 
patient who died yesterday morning with a septic adynamic 
ileus among other things. This case demonstrates exactly the 
importance of that differentiation, and how we are able to make a 
differential diagnosis in these cases. This patient suffered from 
one of the abdominal conditions in which one feels his hands are 
tied, so far as surgical help is concerned. Now listen to the story. 
History. — The patient, a youth aged eighteen years, entered 
the hospital Friday, May i, 1914, with the following history: He 
has had occasional attacks of tonsillitis for years. Six years ago, 
while playing football, he was kicked in the abdomen and suffered 
severe pain for a few minutes. He continued the game, however, 
without further trouble. Two weeks following the accident he was 
taken with sudden severe pains in the locality of the injury in the 
abdomen, soon after which he vomited. Hot poultices were 
applied, and cathartics and an oil enema resulted in a bowel 



SURGICAL AND GENERAL DL^GNOSIS 643 

movement. The pain continued severe for three days, but at 
the end of five days it disappeared completely. He vomited 
only once during this illness. No blood was noticed at any time 
in the emesis or stools. ^ 

He has been otherwise in excellent health up to Wednesday, 
April 29, 1 9 14, when about noon he noticed a sHght soreness of 
the throat when he swallowed. The soreness increased during 
the afternoon. About 6 p. m. he felt nauseated and vomited. 
The nausea continued from Wednesday evening until Thursday 
morning, and he vomited twice during the night. About mid- 
night he felt very sick. He had no chills, but had some fever 
since late on Wednesday afternoon. The fever has continued up 
to the present time. 

About Thursday noon, April 30th, he felt better and the 
soreness in the throat was not so marked as on the previous 
evening. At 7 p. m. Thursday evening he was taken with sudden, 
severe, cramp-like pains over the whole abdomen, soon after 
which he became nauseated. At 10.30 p. m. he vomited. 
About 10 p. M. he was given a cathartic and an olive-oil enema 
and a normal bowel movement resulted, but did not relieve the 
pain. The vomiting continued from 10.30 P. M. Thursday until 
about 6 A. M. Friday, when the pain became more severe over the 
right lower quadrant of the abdomen, with marked tenderness 
over the whole of the lower abdomen. The entire abdomen 
was somewhat tender and was not distended, but scaphoid. 

His physician took his temperature and states that it ranged 
from 101° to 102° F. all day Friday. On Friday at 9 A. m. his 
white blood-count was 19,000; at i p. m., 21,000; and at 3 p. m., 
20,000. When he entered the hospital at 10 p. m. Friday it was 
15,200. His temperature was 102° F., pulse 120, and respiration 
30. There was marked rigidity over the entire lower abdomen. 
The greatest point of tenderness was in the right lower quadrant. 
He feels most comfortable lying on his back. 

The throat was inspected and some small white patches were 
seen on the tonsils. A culture was made from the throat and 
showed a pure culture of diplococci, with the morphologic and 
cultural characteristics of pneumococci. 



644 CLINICS OF JOHN B. MURPHY 

Dr. Murphy: Where was the first pain that he had? Put 
that down in black letters and then underscore it. He had a 
sore throat firsti Note the significance of that statement in the 
record. Then he had nausea and vomiting, but no chill. His 
temperature began gradually to rise, and then, over twenty-four 
hours after the onset of the sore throat and the initial vomiting, 
he complained of abdominal pain for the first time. Such an 
onset means that this was not a simple appendicitis case, because 
abdominal pain is the initial symptom of appendicitis; then come 
nausea and vomiting; then the local sensitiveness in the right 
iliac fossa, and, lastly, the elevation of temperature. All these 
other symptoms preceded the abdominal pain in this case. These 
facts explain why we acted in a definite way and why we made an 
unfavorable prognosis as soon as we had gone over the boy's 
case. After the onset of the abdominal pain came the secondary 
nausea and vomiting, associated with the secondary metastatic 
lesion in the abdomen, and differing in character from the febrile 
nausea which he had with his primary lesion in the throat. On 
examining the boy it was at once noticed that his abdomen was 
drawn in and motionless — a scaphoid abdomen; that all his 
breathing was costal, none diaphragmatic, and his respiration 
sighing. 

He still had evidences of his angina. There were spots of 
exudate over his tonsillar crypts, and cultures from these spots 
showed a pure growth of Gram-positive diplococci resembling 
the pneumococcus. What was the diagnosis? It was a strepto- 
coccus or pneumococcus infection of the peritoneum, probably 
metastatic from his throat infection. I have performed laparot- 
omy in three of these cases up to the present time, in only two 
of which did the infection originate in the throat. The other 
originated in the finger. All three were generaUzed strepto- 
coccus infections, perhaps metastatic in the appendix, and passing 
out from there to the peritoneum without the development of a 
perforation. That patient with the infected finger had the high- 
est polymorphonuclear leukocyte count I ever saw— 80,000; it 
went up from 26,000 to 80,000 in the forenoon of a single day. 
Of that type of peritonitis we had a number of cases here in 



SURGICAL AND GENERAL DIAGNOSIS 645 

Chicago two years ago, during the epidemic of milk-borne strepto- 
coccus sore throat, reported by Capps, Miller, and Davis, like- 
wise a number of deaths. This boy is the first case that I have 
seen this year. In the three cases which I operated the appen- 
dices were not perforated. They were red and infiltrated, and 
all around them there was subperitoneal infiltration. The peri- 
toneal cavity was dry, but the peritoneum was red and bhstered 
as though hot mustard water had been poured on it. All three 
patients died. This type of peritonitis does not benefit by 
drainage. Practically all the cases operated on two years ago 
died. I decided that if I operated this boy he would probably 
die more promptly than if let alone, because this condition is 
essentially a bacteremia rather than a peritonitis. Saturday 
morning, less than three days after the onset, he was aheady 
cyanotic. Cyanosis is a forerunner of the end in these cases. 
His cyanosis increased during the day and evening. His pulse- 
rate kept gradually going up and up. Piano percussion over 
the abdomen showed no accumulation of fluid at any time. He 
died Sunday morning, and was perfectly conscious to within ten 
minutes of the time of death. 

The young men in the profession have not seen many cases 
of this class. We did not have this particular type of peritonitis 
in the male sex in Chicago until two years ago, when they were 
recognized in quite a number of cases during the streptococcus 
sore-throat epidemic. That type of peritonitis we saw very 
frequently, however, in puerperal women during the preanti- 
septic days, particularly when I was a student and an intern. 
This is the same type of streptococcus peritonitis that we saw 
following parturition in those times. I remember opening the 
abdomen of such women at autopsy in the Cook County Hos- 
pital Morgue, and would be surprised not to find even a tea- 
spoonful of pus in that whole abdomen; but there were always 
one or more bhstered areas where the entire endothelial covering 
of the peritoneum was gone. The edema and the infiltration lay 
beneath the peritoneum. It was not a genuine peritonitis. It 
was primarily a subperitoneal infection of the cellular tissue of 
the broad ligament, and from the broad ligament the infection 



546 CLINICS OF JOHN B. MURPHY 

would spread behind the rest of the peritoneum. We did not 
have an autopsy on this boy, we are sorry to say, but there 
could be no question as to the diagnosis after a careful considera- 
tion of the clinical course of the case, the way in which it began, 
the sequence of the symptoms, and, finally, the characteristic 
termination. We did everything possible to counteract the 
infection, but in vain. We had an autogenous pneumococcus 
vaccine from his throat ready in eighteen hours. We used 
Steam's streptolytic serum before the vaccine was ready, but 
the course ol the affection was not appreciably altered by either 
of these remedies. The disease was fatal so rapidly that the 
patient died before the vaccine had time to augment his re- 
sistance. Remember, a vaccine is different from a serum. A 
vaccine supplies only the stimulus for the production of resistance 
to infection. A serum contains the resisting material itself, 
complement, with or without immune-bodies. Therefore, these 
two preparations are entirely different in their action and effect. 
He vomited, as I remember, only two or three times after the 
initial vomiting, a rather constant feature in this type of general 
peritonitis. There was no visible or audible peristalsis, and yet 
no distention to speak of up to the time of death. There is not 
much distention in thJs class of cases, as a rule, thus differing from 
the slower type of generalized peritonitis in which the patients 
become enormously distended before the fatal termination. 
There was, presumably, no mechanical obstruction to the in- 
testines at all in this boy's abdomen. There was merely a 
paralysis of peristalsis, due to the generalized subperitoneal 
phlegmon. 

When we come to differentiate between the varieties of 
adynamic ileus, from a symptomatic standpoint, they appear 
very different. Most all of them have pain of some sort at some 
time. Many of them have nausea and vomiting. Others have 
local sensitiveness, and others have gaseous distention of the 
abdomen. The order and intensity of the symptoms vary, 
depending on the type of lesion. Let us consider Class 6, the 
septic variety of adynamic ileus. These septic cases have 
practically always, except in embolism of the bland type, an 



SURGICAL AND GENERAL DMGNOSIS 647 

elevation of temperature in the early stage. With the cases of 
Class 3, ileus due to spinal cord lesions, there is no elevation of 
temperature. Unless one pays strict attention to the cHnical 
history, one may make very serious errors in the diagnosis of 
many of these cases, particularly in the cases of embolism. I 
have not seen more than half a dozen cases all told, but that is 
enough to give me a fairly clean-cut picture of the subject. Let 
me cite a typical case: A man, whose picture we have shown 
many times in this cUnic because of the splendid result which we 
secured for him in an ununited fracture of the neck of the femur, 
had one of these chronic, recurring, endocardial lesions. While 
he was still in the hospital he had a sudden attack of severe 
precordial distress and dyspnea, with a pulse rate of 145, followed 
by a sudden pain in his right side, and the early development 
of jaundice; he was terribly sick. We made a diagnosis of an 
embolus in his liver. He recovered from that incident and went 
home perfectly well, apparently, except for his endocardial lesion. 
He was home only a few days when his local doctor was called 
in one evening in a great hurry. The patient said he had a severe 
pain in his abdomen — ^more severe on the right than on the left 
side; then he became nauseated and vomited. He had some 
local abdominal sensitiveness, more pronounced on the right 
side than on the left. He had a temperature of 100.5° F. Such 
an onset would make any one think of an appendicitis ; but when 
the nurse counted his pulse immediately after the onset of his 
pain, its rate was 148 per minute. That observation told the 
whole story. A man with an acute appendicitis has no right to 
have a pulse of 148 within a few minutes of the onset of his pain; 
but a patient through whose heart an embolus is passing, or has 
recently passed, may have a pulse of 148, 160, or 170. I was in 
New York at the time, and, as the patient was Hving in New 
Jersey, near New York, I was asked to come in consultation. I 
could not come, however, because I was scheduled for an address 
in New York the same evening. So I talked over the phone with 
the doctor who had the patient in charge. He was calling it an 
appendicitis. I said, "Doctor, that does not sound exactly like 
an appendicitis to me. It sounds rather like an embolism of his 



648 



CLINICS OF JOHN B. MURPHY 



mesenteric artery, owing to that sudden increase m the pulse- 
rate associated with the abdominal pain. '' I also remmded hmi 
of the chronic endocarditis and the Uver embolus. He is a very 
able man and operator, and you have heard me quote him here 
again and again; but he paid very scant attention to my tele- | 

phone diagnosis. What happened? When the abdomen was 1 

opened, a gangrene of almost the entire small intestine was found. 1 

The oi^rator was at a loss to know what to do, because he had 
not figured on just that eventuaUty. He might have tried to 
extract the embolus or resect the intestine, but he did not. He 
sewed up the abdomen instead. He performed the operation 
under local anesthesia, which was another mistake in a case of 
this kind, where much intestinal manipulation was necessary. 
Whether it would have made any difference so far as the life of 
the patient was concerned to resect the intestine I cannot say. 
My apology for citing this case is the necessity of accentuating 
this important diagnostic point in the history, that a patient 
with an acute appendicitis does not have so rapid a pulse as 140 
at the onset of the disease. 

The next variety of ileus in which one is likely to make a very 
serious error is that due to diaphragmatic pleurisy or to throm- 
bophlebitis. Thrombophlebitis is not at all as sudden in its 
onset as an embolism, but it is just as surely fatal. Such a 
thrombophlebitis in the portal system is usually the inflammatory 
sequence of some operative procedure, such as an operation for 
hemorrhoids, for appendicitis, or for pancreatic abscess. It may 
also be the sequence of metastatic infection of the mesentery 
from an abscess or a phlegmon in other positions in the body. 

Diaphragmatic pleurisy is associated most commonly with 
pneumonia. It often begins with pain over the abdomen, either 
on the right or on the left side, depending on which pleura is 
" involved. The patient voluntarily minimizes diaphragmatic 
respiration in order to diminish the pain produced by the dia- 
phragmatic friction. The diaphragm becomes immobilized 
chiefly by the abdominal walls becoming contracted and spastic. 
There is usually more or less local sensitiveness in the same area 
as the referred pain. There is usually more or less paralysis of 



SURGICAL AND GENERAL DLVGNOSIS 649 

peristalsis, depending chiefly on the degree of elevation of the 
temperature. An elevation of temperature, remember, is never 
present primarily in a mechanical obstruction. That fact is a 
great help in the differential diagnosis. 

Let me relate the history of a case of this kind to show the 
mistakes it may give rise to : I was called up on the long-distance 
phone from a town a distance of about 100 miles from Chicago, 
and asked to come out to see a child who was said to have an 
acute intestinal obstruction. The child was then in the third 
day of the obstruction. I asked the doctor for the history of the 
case. He told me that the child was taken ill three days pre- 
viously with severe pains in the abdomen, accompanied by 
nausea and vomiting, which is common with children in the be- 
ginning of an infection, and, on the evening of the onset, a tem- 
perature of 103° F. The fever had continued without inter- 
mission since the onset. Just that one fact — the presence of 
fever with the onset of the disease — made it certain that this 
was not a primary mechanical obstruction with which we had 
to deal. I told the doctor that I thought the case was probably 
one of appendicitis, and went out prepared to perform an ap- 
pendectomy. Upon examination of the child I found the ab- 
domen enormously distended and tympanitic, and sensitive 
everywhere on the right side. Palpation of the abdomen was 
almost futile on account of the distention. Then I turned the 
patient over to examine the back and lungs, and found a complete 
consolidation of the right lower lobe of the lung, due to a typical 
lobar pneumonia with the usual accompanying diaphragmatic 
pleurisy. That she was not operated goes without saying. 
These cases of diaphragmatic pleurisy which are brought here 
to the hospital for operation under the diagnosis of some ab- 
dominal condition or other are so numerous that we make it a 
rule never to diagnose acute appendicitis without carefully 
examining the patient's chest to rule out a pneumonia or a 
pleurisy. The same precaution, of course, is necessary in cases 
of suspected ileus. Unless one constantly bears in mind these 
sources of error, he is sure to come to grief some day on one of 
these stumbling-blocks. 



550 CLINICS OF JOHN B. MURPHY 

Let us consider how the symptoms of the mechanical type of 
obstruction differ from the intestinal paralysis of the two other 
types of ileus. With the mechanical type of obstruction there is 
always pain in the adult patient, recurrent and colicky in type; 
then nausea and vomiting, the vomiting increasing as the length 
of time from the onset increases, thus differing radically in type 
from the reflex variety of vomiting, the type characteristic of 
dynamic and adynamic ileus, which diminish as the length of 
time from the onset increases. The presence of borborygmus is 
another useful sign. This sound is due to the small explosions 
which occur in the dilated bowel in the effort of the peristaltic 
waves to overcome the obstruction. The stethoscope is just as 
important in making the differential diagnosis between different 
abdominal conditions as it is in the differential diagnosis between 
lesions in the chest. With mechanical ileus without infection 
there is always borborygmus present, due to an increase in per- 
istalsis, which is often stormy, and which one can sometimes hear 
with one's back turned to the bed. Peristalsis may then be 
heard increasing and increasing until suddenly there is an ex- 
plosion. If one follows the sound carefully two or three times 
with a stethoscope, one may be able to put the stethoscope 
directly over the site where the obstruction exists. That is 
where the explosions occur with maximum intensity. That is 
where the muscle of the bowel relaxes and there occurs a sudden 
backward rush of gas and fluid, which has been forced under 
pressure against the obstruction. 

Perhaps the point next in diagnostic importance after bor- 
borygmus is emesis. Vomiting is of a peculiar type with me- 
chanical ileus. It is chiefly of the overflow type. The lower 
the obstruction in the alimentary tract, the larger the quantity 
of overflow of intestinal contents. The vomiting at first is 
purely of the overflow type, gradually increasing in amount and 
frequency. For a while, in the early stage of the obstruction, 
the patient vomits into a basin; but as time passes without 
relief of the obstruction a point is reached where he just spews 
it out, sometimes throwing it five or ten feet across the room, the 
expulsion comes with such a rush. That is the character of the 



SURGICAL AND GENERAL DIAGNOSIS 65 1 

superlative overflow vomiting peculiar to the mechanical t3^e of 
obstruction. The muscles of the bowel, stomach, abdominal 
wall, and the diaphragm probably all play a r61e in the violent 
expulsive efforts. In the mechanical type of ileus the violence 
of the vomiting always increases as time goes on, but in the 
non-mechanical types, such as one sees with a strangulated 
omentum, a stone in the common duct, or a stone in the ureter, 
the vomiting, which is a reflex from peritoneal irritation, di- 
minishes constantly. 

Temperature and leukocytosis are the signs next in impor- 
tance. Fever is never present in the mechanical type primarily. 
I keep reiterating this fact because of its importance. You 
know at once that with a temperature of from 101° to 102° F. 
you have some other condition than a mechanical ileus to deal 
with, most Kkely some infection or some inflammatory associa- 
tion which produces only a reflex or inflammatory paralysis of 
the bowel, not a mechanical obstruction of the lumen of the 
canal. 

Leukocytosis may be high or low, being chiefly dependent 
on the condition causing ileus. It is more commonly of medium 
degree. The late Dr. McDonald, of Albany, reported a leuko- 
cytosis of 37,000 in a case of mechanical ileus. That is a very 
exceptional count. We cite it because it gives you an idea of the 
upper limit of leukocytosis in these cases. 

The next element in the diagnosis is the physical examination. 
What can one find on physical examination in a case of mechan- 
ical ileus? If the examination is carefully made, and if the ob- 
struction Hes low down in the alimentary tract, one may find 
areas of flatness. Areas of flatness may be interspersed among 
areas of resonance, and may be clearly outlined on a careful ex- 
amination of the patient. The point of greatest resistance in 
the abdomen is apt to be located over the site where the obstruc- 
tion is located. Change of position does not commonly change 
the line of flatness in mechanical ileus, whereas in paralytic ileus, 
particularly in the type due to afferent nerve lesions, there may 
be markedly movable areas of flatness, especially in the flanks. 
I recall the case of a police officer who was shot in the neck by a 



6^2 CLINICS OF JOHN B. MURPHY 

burglar whom he was chasing upstairs. The bullet passed into 
his mediastinum— just where it went I do not know. I saw the 
patient on the skth day after the shooting. He was originaUy 
Dr. Fenger's patient, but the doctor had gone to the country and 
asked me to look after the case in the Cook County Hospital. 
I went over him very carefully. His abdomen was enormously 
distended, and he had had no bowel movements since the injury. 
He had then a temperature of only ioo° F. and a fraction, but he 
had very freely movable dulness in both flanks. I therefore 
decided that the bullet must have passed down through the 
mediastinum and the diaphragm into the peritoneal cavity, and 
that this fluid which rolled so readily from one side of the ab- 
domen to the other was free in the peritoneal cavity, probably 
consisting of extruded intestinal contents, blood, and inflam- 
matory products. Accordingly, I advised a laparotomy. When 
we opened the abdomen, his intestines bulged out, of enormous 
size, but smooth and shining, and otherwise in good condition. 
There was no free fluid in his abdomen at all; it all lay inside his 
dilated paralyzed intestines and flowed from side to side on 
change of position in the dilated loops. We closed his abdomen 
without drainage. After the operation, for some reason or other, 
peristalsis started up, his bowels began to move, and he made an 
uneventful recovery, in spite of our interference, because I do 
not believe that my operation contributed at all to his recovery. 
He is carrying the bullet yet, so far as I know. I cite that case 
to show how complete the intestinal paralysis is in such cases, 
and how deceptive a freely movable abdominal flatness may be. 
Some conclusions may be drawn from the type of material 
which the patient vomits. First, the vomitus is apparently 
mucus or stomach-contents, which later become stained with 
bile. Then the character of the vomitus becomes a little more 
offensive, and gradually more so. You read in the Hterature and 
in the text-books many times of the presence of fecal vomiting 
in ileus and its diagnostic significance. I have seen fecal vomit- 
ing only three times in my entire experience, reaching over a 
third of a century. Fecal vomiting occurs only so shortly before 
death that it just misses out on becoming one of the postmortem 



I 



SURGICAL AND GENERAL DLVGNOSIS 653 

signs of intestinal obstruction. The doctor who waits for the 
presence of fecal vomiting before diagnosing ileus will pass the 
undertaker on the patient's doorstep. Disregard it as one of the 
signs of intestinal obstruction. It does not occur sufficiently 
often to be considered; but the offensive vomitus of pea-soup 
consistence is particularly significant of ileus, and is, perhaps, 
what many cKnicians call fecal vomiting, particularly significant 
if, after washing out the patient's stomach, it fills again. 

Borborygmus is a manifestation of the contraction of the 
bowel, and is, therefore, one of the most important signs of 
mechanical obstruction, and one of the signs which is commonly 
destroyed by the doctor by giving the patient with ileus a hypo- 
dermic injection of morphin, and producing a paralysis of per- 
istalsis and a consequent absence of borborygmus. Never give 
morphin to deaden pain in the presence of a suspected mechanical 
obstruction of the bowel. Morphin fogs the danger-signal of 
obstruction. A morphinized patient may continue with his 
ileus, apparently in a comfortable condition, until death is upon 
him. First make the positive diagnosis of an obstruction and 
then use the hypodermic. Let the patient keep his pain, let him 
cry out with it, until the diagnosis is positively made. Follow- 
ing such a course may finally result in your being relieved of the 
case, but, remember, the loss of such a case is sometimes a bless- 
ing which we do not properly recognize. If you are relieved of 
the case, you know, at least, that you have done your duty so 
far as the patient's best interests are concerned, and the patient's 
interest takes precedence over all other things. 

SUBSEROUS UTERINE FIBROID— THE RELATIONS OF 
UTERINE TUMORS TO MENSTRUAL FLOW— DIF- 
FERENTIAL DIAGNOSIS 



HISTORY 



This patient is a married woman of forty-eight. The patient 
has been married for eighteen years and has never been preg- 
nant. Her past history is negative, except for pneumonia at 



554 CLINICS OF JOHN B. MURPHY 

forty-four years. Her menstrual history began at fourteen 
years of age, was of the twenty-eight-day type, and from four 
to five days in duration. She had very Httle pain with the 
periods, and used one napkin a day on the average. She has 
never missed a period. 

In the autumn of 191 1 (three years ago) she first noticed 
that her abdomen was a Uttle larger than normal. About three 
months later she began to have sHght bearing-down sensations 
in her pelvis, and she urinated more frequently than usual, be- 
cause of a feeling that she could not hold the urine. The urine 
was relatively small in amount each time. She thinks the 
twenty-four-hour amoimt was not increased. This condition 
of frequent micturition obtained only in the daytime. She 
urinated normally once during the night. 

The size of her abdomen continued to increase slowly. Two 
years ago, in 191 2, she began to have severe backache when on 
her feet any length of time, and walking, consequently, became 
difiicult. She has had occasional sharp shooting pains over the 
pubis in the midline of the abdomen for the past two years, but 
they have not been severe in character. 

Eighteen months ago, in the autumn of 191 2, she thinks in 
October, her menstrual periods, without apparent cause, changed 
to the twenty-one-day type from her normal twenty-eight-day 
type; but the flow remained normal in amount and duration. 
This condition continued until March, 19 13, when she noticed a 
bad odor accompanying the flow. The odor has increased during 
the past six months. 

She says she had a yellow vaginal discharge two years ago, 
which amounted, however, to only three or four drops every 
four or five days. She was advised then to use boric-acid solu- 
tion as a douche, and she has done so daily ever since. Since 
she has followed this treatment she has never noticed any further 
discharge. She has never had any intermenstrual flow. Her 
last menstruation was April 14, 1914, and was still of the twenty- 
one-day type. 

About six weeks ago, she says, she suddenly became nau- 
seated, vomited, and noticed that the vomitus was stained with 



SURGICAL AND GENERAL DIAGNOSIS 655 

bright red blood. The following day she had a diarrhea and 
the stools were black in color, but she did not feel weak. This 
is the only time she ever vomited or passed blood in her stool, so 
far as she knows. She says that for the past six months she has 
often had pain of a burning character in her stomach from one- 
half to one hour after eating. She refers this pain to the epi- 
gastrium, and says it is often so severe that it wakes her up at 
night. She has never had any cramp-like pains in the abdomen. 
Once in a while the pains over the pubis seem to radiate down 
into the right thigh and groin. She has never had any pain in 
the abdomen or back severe enough to make her acutely sick. 
She has never fainted. She has lost no weight, and feels in good 
health save for these rather mild upper and lower abdominal 
pains and the continual increase in size of her abdomen. 

The tumor in the abdomen is large and hard, is movable, and 
not adherent to the anterior abdominal wall. It feels round and 
smooth, lies directly in the midline, and is not tender. 

COMMENTS 

Dr. Murphy (April 18, 1914) : Has she never missed a period 
up to the present date? 

Intern: No, sir. 

Dr. Murphy: The yellow discharge is never present except 
with menstruation. Did she have any pain at the time when 
she became nauseated and vomited? 

Intern: No. 

Dr. Murphy: Where did she first notice the tumor? 

Intern: In the median Hne, over the pubis. 

Dr. Murphy: If we accept the doctor's history, this trouble 
began originally as a pelvic tumor. According to the story she 
told me, it began as an abdominal tumor. That is a point I 
want to bring out. The doctor's story states that the tumor 
began in the midline. It is now resting on the promontory of 
the sacrum, and is not at present a pelvic tumor. You remember 
how important the story was in that case of ovarian sarcoma 
the other day with rotation of the tumor on its pedicle. (See June 
issue of the Clinics, p. 599.) The only evidence which we had 



556 CLINICS OF JOHN B. MURPHY 

that the ovarian tumor of that young woman began in the pelvis 
was the fact that in the early stage, before she noticed the 
tumor, she had frequent urination, without pain, but with a 
sense of pressure on the bladder. That is exactly the same story 
which this woman told the doctor, but she did not tell me. 
She felt as if her bladder could not contain the urine, she told the 
doctor, and that symptom was present before she noticed the 
tumor. After she noticed the tumor she no longer had the 
urinary difficulty. That statement means that if this tumor 
began as a pelvic tumor, it escaped from the pelvis into the ab- 
domen, and with that escape relieved the pressure on the blad- 
der. If that portion of the doctor's story is true, and it is not 
what the patient told me, this growth began as a pelvic tumor. 

If it began as a pelvic tumor, in what class of pelvic tumors 
does it fall? In analyzing pelvic tumors, the first symptom to 
analyze is menstruation, particularly when the patient is a 
woman in the menstruating period of life. Now, what change in 
menstruation did this patient note? She menstruated regularly 
every four weeks before she had this bladder disturbance. 
During the period of the bladder disturbance she began to men- 
struate every three weeks, but the quantity of flow was not 
materially increased. Finally, when the bladder disturbances 
due to pelvic pressure disappeared, she still continued menstru- 
ating every three weeks, but with no increase in the quantity of 
the flow. 

The reason we go so closely into the particulars regarding the 
increase in quantity of her flow is because increase in the quan- 
tity has a specific relation to certain pelvic tumors, namely, 
fibromata and carcinomata of the uterus. Fibromata of the 
uterus influence the quantity and duration of the menstrual 
flow in a definite way, for a definite reason. They depend on 
the relation which the fibroid bears to the mucosa, rather than 
on the size of the fibroid. That is, you may have a polypus not 
larger than the end of your finger, lying submucous or intra- 
uterine, produce an enormously greater flow than a fibroid so 
large as my hat, which lies subperitoneally. That is an important 
point I want to emphasize. If this patient has a fibroid of the 



SURGICAL AND GENERAL DIAGNOSIS 657 

uterus which is submucous, she should have an increase in the 
amount of her flow — which she has not. If she has a subserous 
fibroid, which lay at first in the pelvis and has now risen out of 
the pelvis into the abdomen, it is not surprising that the amount 
of her flow has not increased either during the past few years or 
at the present time. 

Furthermore, a fibroid influences menstruation not only by 
increasing the daily quantity, but also by increasing the dura- 
tion of the flow. These patients may flow from one period con- 
tinuously into the next, but they practically never have an inter- 
menstrual flow. They may, however, have an intermenstrual 
*'show," for instance, after being jolted in a lumber wagon over 
a rough road or after severe exertion; but this "show" cannot 
be mistaken for a genuine flow. 

A fibroid also postpones the menopause. The patient with a 
fibroid, whose normal menopause would be at forty-six, con- 
tinues menstruating until fifty, fifty-one, fifty-two, fifty-three, 
fifty-four, or fifty-five years of age. Furthermore, these patients 
often continue to menstruate regularly without skipping until 
they come to the final flow. When they skip one month, then 
they are through. 

[Incision; removal of large subserous fibroid; closure. The 
technic of the operation was practically that outlined on page 
763 of the current issue of the Clinics.] 

Now let us examine this specimen. It shows you why this 
woman had practically no abnormal bleeding. You see how far 
from the mucosa that subserous tumor lies. It did not involve 
the mucosa at all, and, therefore, produced no hemorrhage. 
The uterus lies practically entirely separate from the tumor, the 
connection between them being merely vascular. That finding 
corresponds exactly with the cHnical history. Now let us read 
the history again and note how it fits the pathology which we 
found. 

[Intern reads history.] 

Dr. Murphy: When the patient first noticed the tumor it- 
self, it was lying in the middle of the abdomen, already out of 
the pelvis, whence it had escaped. She noticed its presence sud- 
voL. m — 42 



558 CLINICS OF JOHN B. MURPHY 

denly, as is in consonance with the physical findings. The tumor 
first filled the pelvis originally, but did not become noticeable 
until it suddenly passed up into the abdomen. Then she noticed 
an increase in abdominal girth, and then she was reheved of the 
pelvic pressure symptoms. Her menstruation continued to be 
of the twenty-one-day type, without excessive quantity, just as 
it had been when the tumor lay in the pelvis. 

I mentioned the anatomic relations in a fibroid uterus which 
influence menstruation. Let us consider for contrast the diag- 
nostic and menstrual characteristics of a uterine carcinoma. In 
the first place, carcinoma of the uterus practically never pro- 
duces so large a tumor as does a fibroid. The menstrual history 
of a uterine carcinoma is also characteristic; but if the patient 
develops the carcinoma preceding the menopause, she presents 
an entirely different clinical picture from what you see if her 
carcinoma develops after the menopause. The menopause in 
the average carcinoma patient comes early in Hfe; that is, at 
forty-three, forty-four, or forty-five years of age. The meno- 
pause in a patient with a fibroma is always postponed, and that 
postponement of the menopause, if the patient's menstruation 
is regular and not diminishing in quantity, has a definite per- 
centage relationship to the probability of a fibroid being present. 
In other words, if a patient is menstruating at fifty, regularly 
and in full quantity, the chances are 65 per cent, that she has 
a fibroid, even if she has no other symptoms pointing to it. 
When she gets to fifty-five, menstruating regularly and in full 
quantity, the chances are 95 per cent, that she has either a 
fibroid or a uterine polypus. They both have practically the 
same significance, because a uterine polypus bleeds just like a 
submucous fibroid, as a rule. 

Let us see what happens in a case of carcinoma. With a 
carcinoma the menopause comes early, as a rule. These patients 
may stop menstruating at forty-three or forty-four years of age, 
and then, after a shorter or longer interim, suddenly have a 
larger flow, and then in two weeks have another larger flow. 
That occurrence is always very significant as indicating a be- 
ginning carcinoma. The quantity is larger, the duration is 



SURGICAL AND GENERAL DIAGNOSIS 659 

longer, and an intermenstrual flow is almost pathognomonic of 
carcinoma in a woman at that period of life. If, then, the 
patient has passed the menopause two, three, four, or five years, 
and then has a sudden flow larger than a normal menstruation, 
in practically 100 per cent, of cases that patient has a uterine 
carcinoma, no matter what the findings on vaginal examination 
may be. Now, remember, I said "larger than normal." Do 
not interpret that "show" which the old lady has in her seven- 
tieth or eightieth year as a flow. That is usually the bloody 
discharge from either a senile vaginitis, which is often present 
in these women, or from an arteriosclerotic uterine apoplexy. 
If you rub a sponge across the vagina when you put in the spec- 
ulum in a case of senile vaginitis, the vagina bleeds everywhere 
from tiny points. This is a "show, " and not a flow. 

There is still another type of hemorrhage which these women 
have as the uterus becomes senile and contracted, that is, the 
bleeding associated with expulsion from the uterine cavity of a 
uterine polypus. Such expulsion may occur at sixty, sixty- 
five, seventy, and so on, up. The patient usually has some pain 
with the expulsion, or finds herself flowing considerably, so she 
comes to you. You put in the speculum or examine her with 
your finger, and find a uterine polypus which has been extruded 
from the uterine cavity on account of the contraction and dimi- 
nution in size of the senile uterus, and is hanging from the 
cervix. That finding makes the diagnosis of itself. I merely 
mention these exceptional causes of uterine hemorrhage that you 
may have them clearly in mind when analyzing the factors on 
which to make the differential diagnosis. 

As to the prognosis of uterine fibroids, it varies quite mate- 
rially. Once a myomectomy was considered the most dangerous 
of all peritoneal operations. So dangerous was it looked upon 
that it was fifteen years after surgeons became accustomed to 
ligating vessels in the pelvis before Dr. Joseph Price, one of the 
ablest teachers and operators of his time, dared to drop the cervix 
or stump of the uterus back into the peritoneal cavity instead 
of sewing it into the abdominal wound. Why was he afraid to 
drop it back? Because it bled. Why did it bleed? Because 



56o CLINICS OF JOHN B. MURPHY 

the uterine artery was tied en masse with a lot of other tissue. 
It is only since we learned to ligate the uterine arteries by them- 
selves, either by the anterior operation of Kelly, cutting the 
peritoneum, pushing it down, and then ligating the uterine ar- 
teries, or by our posterior operation, which you saw this morn- 
ing—it is only since we began tying the uterine arteries separately 
that the mortality from hemorrhage, which previously was the 
chief cause of death after fibroid operations, has disappeared. 
These fibroid operations, as a rule, are no more dangerous now 
than oophorectomy; they merely take a Kttle more time. 

The next danger in fibroid operations is the danger of infec- 
tion of the stump or peritoneal cavity from the cervix, and this 
danger is not great; in fact, it is almost nothing at all. 

Another danger, and one which is more serious in this par- 
ticular case today, is that of pulmonary embolism. I showed 
you the large veins in the excised specimen. They have been 
traumatized and ligated. Occasionally, therefore, a thrombus 
forms, and that thrombus may loosen and become an embolus 
and lodge in the pulmonary artery. Such an accident is not 
common, but it is sufficiently common in this class of cases to 
take it into the reckoning of the mortality. I recall a patient 
whom I operated for a uterine fibroid in the presence of an exist- 
ing pregnancy. The stipulation in the operation was that if 
the fibroid was so situated that I could take out the fibroid with 
a considerable hope of subsequent retention of the fetus in the 
uterus, I might take it out; otherwise I was to leave it. I was 
not permitted to do a hysterectomy at all. I opened the abdo- 
men and found the fibroid filling the fundus rather high up. I 
did not do an enucleation. Why? Because I felt that the 
fibroid would not materially interfere with delivery. Two weeks 
after the operation the patient suddenly became hemiplegic 
from a crossed embolism. Remember, no operation was actu- 
ally performed in the abdomen; the abdomen merely was 
opened. The embolus involved only a small brain area, and in 
a very short time the symptoms entirely disappeared and she 
was delivered of her baby at full term, without any further 
trouble. I merely cite that case to show that thrombosis may 



SURGICAL AND GENERAL DLA.GNOSIS 66 1 

occur where there is great vascularity, such as is present with 
a pregnancy, practically without traumatizing the arteries or 
veins at all. 

[Pathologist's report: The specimen consists of uterus and 
tumor mass, the latter a large degenerated fibromyoma. The 
endometrium of the uterus shows a hemorrhagic hyperplastic 
endometritis. 

Note. — The wound healed by complete primary union. The 
patient was out of bed in two weeks, and returned home, com- 
pletely recovered, May 7, 19 14. — Ed.] 



ARTHROPLASTY OF HIP 

Meeting of the International Surgical Congress at 
Mercy Hospital, Tuesday, April 21, 1914* 



Dr. Murphy: It is needless for me to say how pleased we 
are to have the members of the International Surgical Congress 
with us this morning. The plan which we have outlined for the 
occasion is this: We shall demonstrate the cases and some of the 
technic of the operations employed. Some of the patients have 
not yet arrived, and while they are coming in, I will talk on other 
subjects. 

The work in which I thought you would probably be the 
most interested is the arthroplasties which we are doing here and 
our technic for them. After the demonstration of cases I shall 
perform an arthroplasty on the hip. I choose that joint since 
it is the simplest on which to demonstrate the technical prin- 
ciples of the operation. 

As you know, in this clinic we have adhered constantly to a 
single method of arthroplasty since 1902, when we first began the 
use of the pedicled flap of fascia and fat. We have always in- 
sisted that this type of operation is essential to success, particu- 
larly in arthroplasties of the weight-bearing joints. That is the 
basis of our operative technic. 

We have laid down the following rule for arthritides which 
subsequently develop an ankylosis, namely, that an arthritis 

*At the clinic held by Dr. Murph}^ on Tuesday, April 21, 1914, for the 
foreign members of the International Surgical Congress, Dr. Murphy showed a 
large number of cases and the results in other cases, many of which have been re- 
ported at various times previously in the Clinics. We are now reporting the 
arthroplasty of the hip which Dr. Murphy performed at this special clinic, and also 
three other cases of arthroplasty of the hip which Dr. Murphy operated that week 
when visiting members of the Congress were present. These cases are now pub- 
lished because of the request of many members of the Congress who saw thern oper- 
ated, to have them in permanent form. To accompany these cases, our artist has 
drawn a special series of sketches showing the operative steps in arthroplasty of 
the hip. 

663 



664 CLINICS OF JOHN B. MURPHY 

which is preceded by a chill with great uniformity results in a 
bony ankylosis of one or more joints. If you remember this rule, 
you have a guide to prognosis and treatment on the initial day 
of the disease. Therefore, we put all these cases with chills at 
once under surgical treatment, the character of which I shall 
outline presently. They are surgical cases, whether you call 
them rheumatism or metastatic arthritis. The sources of meta- 
static arthritis are most commonly, first, the nose; second, the 
pharynx and throat; third, furunculosis; fourth, the tonsils. 

The tonsil is not only frequently the direct source of meta- 
static infection, but is commonly the primary focus of an infec- 
tion which spreads into the pharyngeal lymphatics, and joint 
metastases occur more frequently from the pharynx infection, 
and even from nasal infection, than from the tonsil direct. At 
least, such is my present conviction, based principally on clinical 
evidence. 

Another point which we often make is that there is a definite 
time for arthritic metastases to take place. The reason why we 
as surgeons have failed to connect the primary infection in the 
throat or nose with the secondary arthritis is because of the 
considerable period of time which usually elapses between the pri- 
mary infection and the secondary arthritis. For example, one 
practically never sees a metastatic gonococcus arthritis before 
the eighteenth day, and the great majority of them occur be- 
tween the eighteenth and the twenty-second day, during a defi- 
nite four-day period. 

It is our belief that opening and draining joints are not to be 
advised in these cases. The destruction of the joints can be 
prevented by repeated aspiration of the inflammatory products 
in the joint and by attacking the joint infection by chemical 
means, particularly those which stimulate the polymorphonuclear 
leukocytes in the joint. The chemical which produces the great- 
est polymorphonuclear leukocytosis is turpentine; but we have 
not yet learned to dilute turpentine satisfactorily. We have 
learned to dilute formalin, however, and to use it very satis- 
factorily in a 2 per cent, solution in glycerin in the joints. 

Therefore, we aspirate, inject, and apply extension, keeping 




<3?*/ 



'^' 'fUi 



Fig. 203.— The essential steps in arthroplasty of the left hip by Dr. JSlurpliy s 
fascia-and-fat flap method. 

"Goblet" incision through skin and fascia lata down to the muscles and tro- 
chanter. The lower tip of the upper flap is placed just below the trochanter. The 
downward prolongation of the incision lies along the outer surface of the femur. 



665 




iig. 204. — Ihe llap of skin, fat, and fascia lata has been retracted upward; 
the anterior and posterior borders of the wound are retracted, thus exposing gen- 
erously the great trochanter and its attached muscles. The chain-saw is passed 
on the needle underneath the superior muscle group, chiefly the gluteus medius, 
down to the capsule of the joint, and the trochanter with muscles attached is being 
sawed ofl in the direction indicated by the dotted Une. 



666 




Fig. 205. — The trochanter with its attached muscles is drawn upward, the 
anterior fibers of the gluteus medius muscle having been cut. The capsule of the 
joint is being incised at right angles to the direction of its fibers . In this operation 
it was not necessary to cut either the pyriformis or obturator externus muscles. 



667 




Fig. 208. — Preparation from the under surface of the skin-flap of the Murphy 
pedicled fascia-and-fat-flap for interposition between the freshened ends of the bones. 
The dotted lines indicate the extent of the flap. 

The use of a pedicled, and therefore viable, flap of fascia and fat, interposed 
between the raw bony surfaces of the newly formed joint, is the characteristic 
feature of all of Dr. Murphy's arthroplasty operations. 



670 




Fig. 209. — The interposing pedicled flap of fascia and fat has been passed 
around the gluteus medius muscle posterior to its attachment, and dropped down 
over the acetabulum, to the rim of which it has been sutured with chromicized cat- 
gut. The head of the femur, when replaced, will lie on this flap. 



671 




Fig. 2IO. — The tn>chanier has been nailed back, in place and the cut ends of 
the muscles sutured. Usually, Dr. Murphy uses a continuous suture of phosphor- 
bronze wire to reunite the muscles. The skin is sutured with horse hair and twa 
or three tension sutures of silkworm-gut are inserted, if necessary. 



672 



ARTHROPLASTY OF HIP 673 

the tension off the products of infection in the joint until the poly- 
morphonuclear leukocytes have become stimulated to act as 
phagocytes; then absorption starts. We beHeve that intra- 
articular pressure in the large joints of the extremities is an im- 
portant factor in the destruction of the joints. Many times in 
the knee, for instance, the ankylosis is a small area, not larger 
than a nickel, just where the bones have been pressed together 
during the inflammatory process. We know that if extension is 
made to these joints and the articular surfaces are thus kept apart 
during the inflammatory process, in many cases an ankylosis 
can be avoided. Not only that, but you also at once reHeve the 
pain with the extension. Therefore, we aspirate, inject, and 
apply extension. 

Furthermore, in convalescence and in a recrudescence never 
put a plaster cast on an acute or a subacute arthritis unless you 
desire to favor ankylosis. That is just opposite to our plan of 
treatment of tuberculosis. A tuberculous joint is always put 
in a cast, but a metastatic arthritis never. We beheve that the 
number of ankylosis cases can be materially lessened by applying 
extension instead of casts. 

Once ankylosis has occurred, the usefulness of prophylaxis 
ceases and the problem of cure begins. That brings us to the 
subject of arthroplasty. Ankylosis of the hip has given us rather 
the best results of any of our arthroplasties. An ankylosis of 
the hip which is free from pus at the time of the arthroplasty 
will nearly always give a good result. You will notice that I 
said, ''free from pus." We have been surprised on three oc- 
casions — once in the knee, once in the hip, and once in the elbow — 
to find in the joint a pocket of pus remaining from the primary 
infection. One was a case of post-typhoidal gonitis. There 
was only a small pocket of pus, and we used every means to dis- 
infect it; but it produced an infection, with the result that we 
got a fibrous imion, not a sKding joint. It is our plan now, 
when we find pus in a joint, whether it is sterile, according to 
the bacteriologist's report, or not, simply to clean it out and not 
perform an arthroplasty at that time. We wait until the 
wound is completely healed, and then do the arthroplasty. 
VOL. ni — 43 



674 CLINICS OF JOHN B. MURPHY 

In making the flaps for the hip we have used the same in- 
cision ever since our original operation in 1902, namely, a short 
U-shaped flap over the trochanter, then a straight incision from 
the bottom of the U downward along the outside of the thigh. 
Formerly we sutured the fat-and-fascia flap around the neck of 
the femur in the arthroplasty of the hip. Now we suture it 
around the acetabulmn. 

We believe that in arthroplasty work there must be absolute 
asepsis — a t3^e of asepsis which is not so essential in abdominal 
work. One must endeavor to keep gloves and hands away from 
the wound, and from those parts of the instruments which touch 
the wound, during the operative procedure. I think that this 
absolutely aseptic technic is a large factor in the splendid success 
which Mr. Lane has had with his bone work. This is a technic 
difficult for one to acquire who has been an abdominal surgeon for 
years. In the abdomen one uses his hands for everything; to 
do all of the work with instruments requires the development of 
new reflex arcs in the surgeon's nerve centers; but they can and 
must be developed. 

Better, however, than the performance of a successful arthro- 
plasty is the prevention of ankylosis; this is not only a possi- 
bility, but an actual probability, if proper surgical methods are 
followed. In addition to the measures which I have already dis- 
cussed — aspiration, injection, and extension — we are using auto- 
genous vaccines in all these cases in which they can be prepared. 



PARTIAL ANKYLOSIS OF THE HIP WITH BONY LIPPING 
OF THE ACETABULAR MARGIN.— ARTHROPLASTY 



HISTORY 
The patient, an unmarried woman aged twenty-four, entered 
the hospital with the following history: One uncle died of pul- 
monary tuberculosis; one sister had tuberculosis of the cervical 
glands. Her previous history is negative, except that she had a 
Neisserian infection at twenty years of age, and has had an 
irritating discharge ever since. She gives no history of lues. In 



ARTHROPLASTY OF HIP 675 

January, 19 14, she had a urethral caruncle cauterized, and her 
uterus was cureted in an effort to stop the vaginal discharge. 

Her hip first gave her trouble in September, 1896, when the 
patient was seven years of age. While jumping rope one day she 
suddenly complained of pain in her right hip. She was put to 
bed and a poultice was applied, which was kept on all night. The 
following day the pain was gone, but she limped very slightly. 
This limping continued through the winter. One night, in the 
spring of 1897, she slept in a cold room, with very Httle cover over 
her. The next morning the pain in her right hip was so severe 
that she wept and could hardly step on the leg. She had no 
chills or fever that she remembers. A poultice was put on the 
hip and left on for a day; and for the following two days hot 
applications were made to the hip. These applications reKeved 
the pain, so that one week later she returned to school. Her 
mother noticed then that she limped a Httle more than before 
catching cold. She continued in school for two weeks, when, 
one evening, she was taken with a chill which lasted fifteen 
minutes. Neither she nor her mother remembers anything of a 
fever following the chill, but she at once complained of pain in 
the right hip. An osteopath was called, and he gave her a treat- 
ment the following day. On the fourth day the pain was much 
better and she returned to school. The osteopathic treatments 
were continued for two months, at the end of which time the pain 
was gone, but she continued to Hmp slightly. 

Three months later she slipped with the right foot on an onion 
peeling and felt a stinging sensation in her right hip. The pain 
at once began to bother her again, and she took some more 
osteopathic treatments for two months. She says that at the 
end of the treatments the pain was entirely gone, but she still 
limped because ^'the right hip did not have so free a motion as 
the left. ' ' At this time the patient was eight and a half years old. 

The condition remained about the same until the spring of 
1900, when she was eleven years of age. She had to carry a 
heavy, nine-months'-old baby a good deal at that time. After a 
month of this work her hip began to pain her, and she walked 
with a pronoimced limp. She again took osteopathic treatments, 



676 CLINICS OF JOHN B. MURPHY 

but the pain and the limp gradually increased, and at the end 
of one month's treatment she could not step on the foot. She 
then called a doctor, who put her to bed and appHed a Buck's 
extension. The pain left her at once. She says she had severe 
night-sweats at this time, and that the leg cramped somewhat 
at night. The sweats lasted, she thinks, about three weeks. 
The Buck's extension was left on for two months, and was then 
replaced by a steel brace, which reached from the foot to the hip 
and around the waist. This brace she wore in bed for six weeks. 
Then the brace was removed, she got up, and found the right 
hip was stijff and also the right knee. The knee returned to 
normal in about two months, but the hip remained stiff, although 
painless. This condition has existed up to the present time. 
(This is a typical result of treatment by absolute immobilization 
in acute metastatic arthritis.) 

COMMENTS AND OPERATION 

Dr. Murphy (April 21, 19 14): On physical examination 
there is apparently no motion in this hip. From the x-ray 
plate it appears to me that the joint is malformed. There is 
Hpping of the rim of the acetabulum, which projects over the 
neck of the femur for about an inch. This is not a complete 
ankylosis, for there is still come joint-cartilage left; but immo- 
bihzation appears complete, from the patient's standpoint. She 
is not a very favorable case to treat. In the first place, these 
cases of incomplete ankylosis do not work out so well as the cases 
of complete bony ankylosis, and, in the second place, she has, 
perhaps, had a tuberculous focus in this joint, which there is 
always some possibility of lighting up. 

[The usual pedicled fascia-and-fat flap arthroplasty was per- 
formed after the lipping of the acetabular margin was chiseled 
away. A copious dressing was then applied, and the patient 
placed in a Travois splint in double abduction with extension. 
No tuberculous focus was found. The wound healed by com- 
plete primary union except at one corner, where there was a 
little oozing for a few days. The patient had no fever at any 
time. Passive motion began at the end of three and a half weeks, 




Fig. 211. — Partial ankylosis of the right hip due to bony " lipping " of the ace- 
tabular margin. This bony rim embraces the head of the femur for a distance of 
nearly an inch beyond the normal acetabular margin, and greatly limits all the move- 
ments at the hip, especially abduction. The a;-ray shows no trace of a tuberculous 
focus nor was any suggestion of one found at operation. The present condition, 
therefore, is doubtless the result of a metastatic arthritis. Radiogram made just 
preceding the operation. 



677 




Fig. 212. — Arthroplasty of right hip. The nail refixes the trochanter to the 
femoral neck. The phosphor-bronze wire is the muscle suture. The reshaping of 
the acetabulum and of the head of the femur gives an almost normal contour to the 
joint. This radiogram was made about six weeks after the operation. 



678 













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679 




Fig. 215. — Arthroplasty of the right hip for partial ankylosis with bony "lip- 
ping" of the acetabular margin, the result of a chronic arthritis. This patient was 
oj>erated at the meeting of the International Surgical Congress held at Mercy 
Hospital, Tuesday, April 21, 19 14. This photograph was made July i, 19 14, ten 
weeks after the operation. 



/ 




Fig. 216. — Arlhropbsty of the right hip for partial ankylosis, with bony "lip- 
ping" of the acetabular margin, the result of a chronic arthritis. This |)alicnt was 
of>crttle(i at the meeting of the Intemalional Surgical Congress held at Mercy 
HotpUal. Tuewlay, April 21, 1914. This photograph was made eight weeks after 
the ofieration. 

680 



ARTHROPLASTY OF HIP 68l 

with the extension still on. She began to walk at the end of 
five weeks. She is still in the hospital (July 3, 19 14), and can 
already do almost everything with the operated limb that she 
can with the healthy one. She had no pain at any time, and was 
never given an anodyne. — Ed.] 



METASTATIC ARTHRITIS OF THE HIP FOLLOWING 
TONSILLITIS.— LIPPING OF THE ACETABULUM AND 
FEMORAL HEAD PRODUCING PARTIAL ANKYLO- 
SIS.— ARTHROPLASTY 



HISTORY 

The patient, a married woman aged thirty-three, entered 
the hospital with the following history: 

Her family history is negative for tuberculosis and mahg- 
nancy. She has two children Hving and well. She has had one 
miscarriage, due to an injury. Her husband is living and well. 
She had attacks of tonsillitis frequently until thirty years of 
age. 

The patient states that in January, 1899, while playing 
basket-ball, one of the players fell with her full weight against 
the patient's left knee, striking it on its outer side. The patient 
fell to the ground. On attempting to rise she found herself 
unable to bear her weight on the leg, and had to be carried home. 
The doctor who was called said that the ligaments of the knee 
were torn. He immediately appKed ice-bags to the knee, and 
kept the patient in bed for six weeks subsequently. No exten- 
sion or cast was used. During the time she was in bed she had a 
severe attack of tonsillitis which lasted about ten days. At the 
end of six weeks she was allowed to leave her bed. She could 
then use the knee, she states, and the motion in it was good; but 
the knee itself was tender and gave her a good deal of pain when 
she tried to bear weight on it. She says she had no chills or 
elevation of temperature at this time, except during the attack 
of tonsillitis. The knee remained swollen for about three weeks 
after the injury. 



682 .CLINICS OF JOHN B. MURPHY 

She was able to walk with the aid of a cane. In January, 
1900, one year after the injury, she gave birth to a normal child, 
with normal labor. In June, 1902, she noticed some slight pain 
in her left hip. The pain kept becoming more severe until Sep- 
tember, 1902, when she again had a severe attack of tonsillitis, 
lasting one week, with one chill and a temperature ranging from 
101° to 103° F. After this attack she had to use crutches be- 
cause of the pain in her hip. In 1908 she again bore a normal 
child, with a normal delivery. After the birth of this child her 
hip remained about the same. In 1909 she went to a hospital 
and had her tonsils removed. At this time a Buck^s extension 
was applied to the left leg and kept on for eight weeks. The 
patient received no other treatment. The extension was then 
removed, and she wore a steel brace on the limb from the foot 
to the hip. She wore this brace from the time she left the hos- 
pital, September, 1909, until December, 1909, when it was re- 
moved. She then walked about on crutches. The pain con- 
tinued in both left knee and hip and she could not bear much 
weight on them. 

She returned to the hospital in May, 19 10, and a plaster cast 
was applied encircling her body and the left leg to the ankle. 
This cast was kept on until September, 19 10. Then it was re- 
moved and the patient went home on crutches. Noticing no 
improvement, she again returned to the hospital, in May, 191 1, 
when another Buck's extension was put on and kept on for two 
weeks. When removed, a plaster cast was put on in its place 
and the patient went home. The cast was removed August i, 
X911. She could then bear some weight on the hips and felt 
entirely well. She could walk with the aid of a cane, and her 
pains were gone. 

She returned to the hospital in May, 191 2, and her doctor 
told her she had nearly perfect motion in her hip. 

The left leg is shorter than the right and slightly smaller. 
The patient walks with a cane and compensates for the short- 
ness of her limb by tilting the pelvis. There is a great deal of 
tenderness along the whole of the left side and posterior portion 
of the pelvis and thigh, and also in all the lumbar vertebrae. 



ARTHROPLASTY OF HIP . 683 

The knee is freely movable. The thigh moves freely in the 
anteroposterior direction, but cannot be abducted or rotated. 

COMMENTS AND OPERATION 

Dr. Murphy (April 22, 1914): For what was she in bed? 

Intern: An injury to the knee. 

Dr. Murphy: From what? 

Intern: From a fall. 

Dr. Murphy: That is the point I want made clear. The 
patient was in bed with a knee injury, and while in bed had an 
attack of tonsillitis. When she got out of bed after the ton- 
sillitis she had to use crutches because of the stiffness and pain 
in the joints. There is probably a connection between those 
two facts which it is important not to overlook. 

What do you mean, doctor, by "about the same"? From 
1902 to 1908 was a long time. Do you mean that the hip re- 
mained about the same as in 1902 or as in 1908? Did she con- 
tinue to use crutches or did she get well? Did she have another 
attack of hip trouble in 1908 after the birth of her child? 

Intern: Yes, and she used crutches from 1902 to 1909. 

Dr. Murphy: What was her condition then? 

Intern: She remained in about the same condition from 1902 
to 1909. 

Dr. Murphy: She is constantly incapacitated on account of 
the pain which she has in the left hip. The patient whose hip 
we operated yesterday had her pathologic process further ad- 
vanced than this patient has. The patient of yesterday had an 
incomplete ankylosis of the fibrous-osseous type. When you 
look at the x-ray picture of this patient you see at once that she 
has a bony Hpping of the upper margin of the acetabulum, with 
some thickening of the upper portion of the head of the femur, 
so that she cannot abduct the limb? Why? Because the lipped 
upper margin of the acetabulum impinges on the thickened 
head in abduction. [Shows an anatomic specimen of a similar 
hip with great lipping of the acetabulum and consequent limi- 
tation of abduction, evidently the result of an infection similar 
to that in the present case.] From her history we are able to 



684 CLINICS OF JOHN B. MURPHY 

trace back this joint affection to the infection of the tonsils and 
pharynx. Following the first infection came recurrence after 
recurrence, and she has never been free from pain in the joint 
since it first set in. She probably will not be free from pain un- 
less an operation is performed and the bony overgrowths removed. 
She has some power of flexion and some extension in the hip. 
She has no abduction and, therefore, walks very lame. 

In performing this operation we must endeavor to reestab- 
lish abduction, and also to give her more power of flexion, so 
that when she puts on a high-soled shoe to make up for the short- 
ening of the left limb, she will be able to flex and extend her leg 
and thus walk without a limp. 

I should like to mention, in passing, that the hip case on 
whom we operated yesterday does not see any reason, she tells 
us this morning, why she should be kept in bed. She has not 
had a particle of pain. She has not been given a hypodermic, and 
yet she has not made a single complaint. She was all smiles this 
morning. That is not the rule. We have an extension on her 
which prevents pressure in the hip-joint. That is, of course, why 
she has no pain. These cases are all dressed in extension with 
double abduction of the thighs. We have another patient in the 
hospital with an arthroplasty of the hip to whom we had to give 
from lyi to 2 grains of morphin a day for six or seven weeks 
after the operation. She is the third patient of this class to 
whom we had to give morphin. We had to give it to her because 
she developed a spasm of the adductor muscles of the thigh after 
the operation, which drove the head of the femur into the ace- 
tabulum of that inflamed joint, so that she fairly screamed with 
the pain. All three of these patients acted that way. Two 
men and one woman had the same trouble. Such cases do not 
get rapid results in the way of early use of the joint. This 
woman I have just told you about is now walking on the limb. 
She has no pain and requires no more hypodermics. 

Perhaps I can offer an additional explanation why the patient 
of yesterday has no pain today. The cartilage, which is the 
lensitive surface of the joint,— the semilunar cartilage of the 
knee, by the way, is extremely sensitive, — in this case was prac- 




Fig. 217. — Arthroplasty of left hip for partial ankylosis. The nearly complete 
ankylosis was due to bony "lipping" both of the acetabular margin and of the 
femoral head, abduction being practically nil. This ankylosis was the result of a 
metastatic arthritis following tonsillitis. The radiogram was made ten days before 
the operation. 



68s 




i 



Fig. 3i8. — Arthroplasty of left hip. Remodeling of the head of the femur and 
oi the acetabulum. This radiogram was made five weeks after the operation. 
The nail is still holding the trochanter in place Phosphor-bronze wire was used 
for the muscle suture, and can be seen in this radiogram lying just external to the 
trochanter. 



686 




Fig. 219. — Arthroplasty of the left hip for partial ankylosis due to bony "lip- 
ping" of the acetabular margin and femoral head, the result of metastatic arthritis 
following an attack of tonsiUitis, This patient was operated April 22, 19 14, in the 
presence of members of the International Surgical Congress. This photograph was 
taken June 15, 19 14, nearly eight weeks after the operation. 



687 




i 



Fig. 220.— Arthroplasty of the left hip for partial ankylosis due to bony 
"lipping" of the acetabular margin and femoral head, the result of metastatic 
arthritis following an attack of tonsillitis. This patient was operated April 22, 
1914* in the presence of members of the International Surgical Congress. This 
phoioffraf»h was taken June 15, 19 14, nearly eight weeks after the operation. 



688 



ARTHROPLASTY OF HIP 



689 



tically all destroyed. What was not destroyed by disease we 
destroyed at the operation. We cleaned it all out just as we do 
in operating for a complete bony ankylosis, and in doing so, we 
got rid of the most sensitive portion of the joint. 

We had to use on that joint what we do not expect to use here 
— the chisel. We hope to get along without it here because the 
bony overgrowth is not so extensive. This woman is not at all 
as pleasant a case to operate, however. She is very stout, and 
fat is always a detriment. If she had one-third the fat she has, 
we should be very much happier. Our technic will be practically 
the same as yesterday. 

It is possible that when we expose this joint we may find that 
the Hpping is the all-important factor. If the articular sur- 
face proves to be in good shape and the lipping is the principal 
pathologic change, then we shall perform only the lipping oper- 
ation, that is, we shall remove the excess bone, connective tissue, 
and periosteum, and endeavor to stop the reproduction of bone — 
which we are not always able to do, however. 

We make the skin incision just as we should if we expected 
to interpose the usual pedicled flap of fascia and fat. We shall 
make a shorter bow in this incision than usual, on account of the 
great quantity of fat present, because this fat will stretch easily 
and give us plenty of space. [The usual pedicled fascia-and-fat 
flap arthroplasty was then performed.] 

Let the record show that the lipping seen in the :x;-ray picture 
was identical with that found at operation; that the bone of 
the acetabulum and femur was soft and spongy; that there was 
a small pocket of granulation tissue at the base of the neck 
of the femur, which possibly contained microorganisms of infec- 
tion; that after removing the lipping from the rim of the acetab- 
ulum the lipping on the neck of the femur was also removed; 
that a pedicled flap of fascia and fat was inserted between the 
head of the femur and the acetabular cavity; that the head was 
reamed off and the acetabulum cleaned out preparatory to the 
interposition of the flap; that the trochanter was put back in 
place with a nail driven in to fasten it in the usual way. Let 

the record also show that the hemorrhage was less than usual. 
VOL. ni — 44 



690 CLINICS OF JOHN B. MURPHY 

There will be a certain amount of tension on the horse-hair 
skin sutures on account of the large quantity of fat present. 
We dress this woman, just as we did the patient yesterday, in the 
Travois splint, with extension and abduction and without a cast, 
the foot directed straight forward and secured in that position. 
In applying the dressing we must first get her square on the 
table. It is difficult to control the disposition of the limbs with 
that quantity of fat present. On account of the difficult control, 
one feels a little more apprehensive about such fat individuals 
than about such a lean person as the patient of yesterday. 

In lifting the patient from the operating-table into the splint 
we are careful to keep all force off the hip, because there is dan- 
ger, during the lifting of the patient, of dislocating the head of the 
femur out of the socket. This is the most dangerous part of the 
after-treatment, and, therefore, we are always anxious about it. 
The Buck's extension is applied to keep pressure off the fat-and- 
fascia-flap in the joint. We must also prevent the external rota- 
tion of the thigh, which occurs so readily in these stout people, 
by fastening the toes straight forward. All these details must 
be looked after with special care in a fat patient. If the head 
became dislocated now, the result of the operation would, of 
course, be a complete failure. One of these arthroplasties on a 
fat patient is about enough to make one feel as if he has finished a 
day's work. 

[Healing by complete primary union; she was out of bed in 
exactly five weeks, walking on crutches. She left the hospital 
June 13, 1 9 14, with already very satisfactory motion in all 
directions. She could then sit in a chair in perfect comfort and 
walked without a crutch but with a cane. — Ed.] 

BONY ANKYLOSIS OF MULTIPLE JOINTS.— ARTHRO- 
PLASTY OF THE HIP 



HISTORY 
THE patient, a man aged thirty-six, entered the hospital 
because'of stiffness of the hips, knees, elbows, and wrists. The 
hips arc the joints most affected. He gives the following history 




Fig. 2 21. — Arthroplasty of the right hip for complete bony ankylosis. This 
patient had a bony ankylosis of both hips and of many other joints also, the result 
of metastatic arthritides. He was operated in the presence of members of the 
International Surgical Congress April 24, 19 14. This photograph was taken June 
15, 19 14, less than eight weeks after the operation. 



691 




Fig. 222. — Arthroplasty of the right hip for complete bony ankylosis. This 
patient had a bony ankylosis of both hips and of many other joints also, the result 
of metastatic arthritides. He was operated in the presence of members of the In- 
ternational Surgical Congress April 24, 19 14. This photograph was taken June 
IS. 19 14. less than eight weeks after the operation. 



6Qa 




Fig. 223. — Arthroplasty of hip. Before operation. Complete bony ankylosis 
of right hip in partial adduction. This patient had complete bony ankylosis not 
only of both hips but also of manv other joints as well — all the result of metastatic 
arthri tides. 



693 




Fig. 224.— Arthroplasty of hip. The nail refixes the trochanter to the neck of 
the femur. The phosphor-bronze wire is the muscle suture used. This radiogram 
was made seven weeks after the operation. 



694 



ARTHROPLASTY OF HIP 695 

of his trouble: In January, 1894, when he was seventeen years 
old, he had been skating all one evening, became very warm, 
and then had to drive about three miles home in an open rig. 
He cooled off very quickly on the way, and arrived home feeHng 
cold. Within thirty-six hours his left knee became very painful 
and began to swell. He does not remember any distinct chill 
preceding the pain, but he did not feel well on the preceding day, 
and thinks he had some elevation of temperature. About three 
days later the left ankle became painful and began to swell. 
He cannot remember any chill preceding this new involvement. 
The joints remained extremely painful, the knee getting better, 
however, as the ankle became involved. Within ten days he 
was over the trouble and was up and around, with no stiffness. 
His physician told him that his heart was sHghtly involved during 
the attack. 

In 1898 he began having pain in the small of his back, and 
shortly thereafter he noticed that the back seemed to be getting 
stiff. In 1899 he had a long siege of typhoid fever. He recov- 
ered from this illness without its having any apparent effect on 
the back ailment, which continued gradually to grow worse, 
paining him a great deal at night. In 1905 he began having 
pain of an indefinite character in his knees. The ache would 
come and go, but never incapacitated him. In 191 1 he noticed 
that his right hip was becoming stiff. He had had considerable 
pain in the joint previously. Shortly thereafter the other hip 
became similarly involved. The pain disappeared before long, 
but the stiffness has continued until the present time. Now he 
has practically no use of the hips at all. 

Shortly after the hips became stiff the knees were slightly 
involved, but the disease here has not progressed very much. 
In the latter part of 19 10 his ankles and wrists became stiff, but 
have gradually improved since then. At the present time both 
elbows are quite tender and extension is painful. 

His general health is good; he has had no night-sweats. He 
has never had any nose or throat trouble. His family history is 
negative. Venereal infection is denied. 



696 CLINICS OF JOHN B. MURPHY 

COMMENTS AND OPERATION 

Dr. Murphy (April 24, 19 14): This patient has a bony 
ankylosis of both hips. He has very great limitation of motion 
in both knees, a little more in the right than in the left, and com- 
plete ankylosis of his spinal column, except for slight rotation of 
the head. He is just one stiff, ossifying mass. He is out of 
commission for either comfort or service. 

What we shall try to do for him is, first, to give him one 
movable hip, so that he can do some walking. In a year or so 
we shall try to give him another movable hip. Then we shall 
operate one joint after another imtil the joint functions are 
restored as far as possible. 

If you try to spread a double ankylosis by using forcible 
abduction, you are very liable to fracture the neck of the femur. 
They snap right off like pipe-stems. One must exercise much more 
care in the manipulation of a case like this than in the average 
hip, because of the relative ease with which such femurs break. 

[The usual pedicled fascia-and-fat flap arthroplasty was then 
performed. There was found a complete bony ankylosis of the 
head of the femur to the acetabulum, throughout the entire extent 
to the acetabular margin. After exposure in the usual manner 
by removal of the trochanter, the fascia-and-fat flaps were in- 
serted in the regular way. The limb was then dressed in ex- 
tension. He had a complete primary union, was able to be out 
of bed in five weeks, and has' a good range of free motion in the 
joint now, eight weeks after operation, June 25, 1914. See 
pictures and x-rays. — Ed.] 

BONY ANKYLOSIS OF THE HIP, WITH SOME ABSORP- 
TION OF THE HEAD OF THE FEMUR.— ARTHRO- 
PLASTY 

HISTORY 
The patient, an unmarried woman aged twenty-eight, en- 
tered the hospital with the following history: Her mother had 
tuberculosis. The patient's own past history is negative, except 
for frequent attacks of tonsillitis. 



ARTHROPLASTY OF HIP 697 

During the first week in October, 1907, after being out all 
day in the rain, she noticed a sHght discomfort and ache in the 
right hip. The following day the pain was severe and she could 
scarcely walk. She had no fever or chills at any time. The 
pain in the hip continued until December, 1907, when she went 
to a hospital, where a Buck's extension was applied. She re- 
mained in the hospital until February, 1908. She left the hos- 
pital with a steel brace and a high shoe, which she wore until May, 
1908; thereafter she walked without a cane. After the extension 
was removed in February, 1908, she says that the hip was stiff, 
but the pain had entirely left her. 

In August, 1909, she went to a hospital, where the limb was 
manipulated under ether. She did not succeed in regaining 
motion in the hip. She then went home and could still walk 
with the aid of a cane. In January, 1911, she reentered a hos- 
pital in the East, and a *' Murphy arthroplasty" operation was 
attempted on the hip. During the first week after the operation 
the hip became infected, and for two months afterward she ran a 
temperature of from 101° to 105° F., with many chills. When 
she got out of bed after an illness of seven months, the hip was 
still stiff, and, in addition to that, both knees and the left hip 
were also stiff. She had, for about nine months following the 
operation, weekly manipulations which helped sKghtly the left 
knee; but the right knee and the left hip remained stiff. She 
remained in the hospital until January, 19 14, a period of twenty- 
nine months. She then went to another hospital and remained 
there until March, 19 14. She received no treatment in this 
second hospital. On April 16, 19 14, she came here to Mercy 
Hospital. 

There is no motion now present in the right hip nor in the 
left. The right knee can be moved about one degree. The left 
knee can be flexed to a point midway between a right angle and 
complete extension. 

COMMENTS AND OPERATION 
Dr. Murphy (May 2, 19 14): About what date in October, 
1907, did her trouble begin? 



698 CLINICS OF JOHN B. MURPHY 

Intern: She does not remember. 

Dr. Murphy: Was it in the early part of October, or late in 
the month, and in what country? 

Intern: Back East, in the early part of the month. 

Dr. Murphy: Back East is a very indefinite proposition. 

Intern: In Massachusetts. 

Dr. Murphy: That is the point I wish to bring out. It 
was in the early fall season, which is the period of predilection 
for these metastatic arthri tides. It was in a region in which, 
in the early fall season, there are cold, chilly days. These are 
the conditions suitable to acquiring infections of the nose and 
pharynx. The metastatic arthri tides are very prone to take 
their origin from these infections. 

The nature of the infection which followed the arthroplasty 
has not been learned. This operation was not done in Chicago. 
She then developed a metastatic infection in her left hip, which 
resulted in a bony ankylosis. One can see from this ic-ray plate 
that this young woman has a bony ankylosis of both hips in 
an adducted position. The thigh comes clear across in front of 
the pelvis, in the worst possible position for repair which a bony 
ankylosis can assume. The jc-ray picture fails to show the 
slightest demarcation of a joint. The infection has entirely 
destroyed the cartilage, and there is, consequently, complete bony 
union. 

Now she has not only a stiff right hip, but also a stiff right 
knee and a stiff left hip; so you see she is pretty much out of 
commission — in fact, she is incapacitated for Hfe unless we can 
do something for that hip. We shall first endeavor to perform 
an arthroplasty on the left hip, although we do not like to operate 
on such fat patients — there is too much blubber in the way. 
That is an element of danger always. You may remember the 
patient we operated on a week ago last Wednesday. It was a 
question with her whether we should cut or blast, she had so 
much fat. She was the patient in whom we had so great diffi- 
ailty in exposing the joint; and yet she has not had an unpleasant 
83rm{>toin since the operation. We did three hip arthroplasties 
last week, three days in succe.ssion, and every one has gone on 




Fig, 225, — Complete bony ankylosis of the left hip with some absorption of the 
head of the femur. This ankylosis followed a metastatic arthritis, the primary 
focus of which was an infected "Murphy arthroplasty" operation performed by a 
surgeon in another city. This radiogram was made on the day immediately pre- 
ceding the operation. 



699 




Fig. 226. — Arthroplasty of left hip. RadioKram made six weeks after the 
operation. Note the restoration of an approximately normal contour to the joint. 
A normal hip- joint shows a clear space between the femur and acetabulum due to 
the relative transparency to the a:-ray of the interarticular cartilage. Such a dear 
SfMce is not to be seen in these restored joints because the cartilage is usually com- 
pletely destroyed by an arthritis severe enough to produce a complete bony anky- 
losis. 



700 




Fig. 227.— Arthroplasty of the left hip for complete bony ankylosis, the re- 
sult of metastatic arthritis from an infected "Murphy arthroplasty" operation 
on the right hip performed elsewhere and resulting in complete bony ankylosis 
of the right hip. The operation on the left hip was performed before members 
of the International Surgical Congress May 2, 19 14. This photograph was taken 
June 15, 1914, six weeks after the operation. 



701 



Fig, 228. — Arthroplasty of the left hip for complete bony ankylosis the result 
of metastatic arthritis from an infected "Murphy arthroplasty" operation done 
elsewhere. The operation on the left hip was performed before members of the 
International Surgical Congress May 2, 19 14. This photograph was made June 
IS, 1914, six weeks after the oi>eration. 



702 



ARTHROPLASTY OF HIP 703 

without an unpleasant symptom. Do not think, however, that 
they all go that way. They give us anxiety every day until they 
are up and walking. That they finally do get good motion is 
demonstrated by the pictures and patients we have shown you 
here. 

This is, furthermore, an unfortunate case to work on, because 
her other hip and her other knee are stiff. The last case I 
operated, a week ago, also had both hips stiff. That was a man. 
He was a thin Httle fellow — so thin one could almost look through 
him. Those are the cases which we enjoy doing. 

[The usual pedicled fascia-and-fat flap arthroplasty was then 
rformed.] 

Let me recapitulate the steps of the operation: First, the 
U-shaped flap was made, which includes in it the skin, fat, and 
fascia lata. One can see that the skin portion of the U goes 
down only about one-half the length of the field of operation, 
because if it went the full distance v/e should have a necrosis of 
the end of the flap, as occurred in some of the earlier cases. 

Second, the trochanter was removed, leaving the muscles 
attached to it. 

Third, a new acetabular cavity was formed and the head of 
the femur was rounded off to correspond. 

Fourth, the pedicled flap of fascia lata and fat was interposed 
between the head of the femur and the acetabulum, and was 
sutured in position to the rim of the acetabulum. 

Fifth, the trochanter was restored to its place by nailing it 
back into position. 

Sixth, the deep fascia was reapproximated and the skin 
sutured. 

Let the record show that there was present in this hip a bony 
ankylosis with some absorption of the head; that the bony 
ankylosis of the head was to the anterior margin of the acetabu- 
lum, all that remained of the head being ankylosed; that the 
head was chiseled free in the regular way; the flaps interposed; 
the trochanter nailed back, and the wound closed in the usual 
way. 

Every step of the operation was like machine work — each 



704 CLINICS OF JOHN B. MURPHY 

piece fitted into the other as we went along. You will note that 
we did not divide the obturator intemus there. We left it still 
attached to the base of the trochanter. The doctor rotated the 
head forward out of the acetabulum. That is the plan we have 
been following lately in place of cutting the obturator and sutur- 
ing it — just rolling the head forward and out. Sometimes there 
is bony or scar tissue interference, and one has to roll the head 
out the other way, or cut the scar tissue and chip away the bone. 
We divided the joint-capsule here close to the head of the femur, 
because the vascular supply enters the head from the vessels of 
the capsule close to the junction of the head and neck, and we 
must, therefore, make our incision close enough to the acetabulum 
so as not to divide these vessels; otherwise necrosis of the head 
of the femur may occur, which is a complication much to be 
feared. 

Let us go over the patient's history again and see how nicely 
it corresponds to the findings at operation. When you have 
this severe type of infection in a joint, forced motion is of little 
or no benefit in restoring the function of the joint. When the 
cartilage is destroyed, it does no good to attempt to reestablish 
motion by putting the patient asleep and applying force to the 
joint. In the acute inflammatory condition, of course, forcible 
manipulations are entirely out of place. 

Intern: [Rereads the history.] 

[Note (July j, 1914). — Complete primary union. The 
patient was out of bed in about five weeks. Passive motion was 
begun at the end of four weeks, with the extension apparatus 
still in place. She walks about on crutches, but cannot walk 
without them, of course, because of the complete bony ankylosis 
in the other hip. She already has a satisfactory and free range 
of motion in the joint in all directions. She is free from pain 
except on excessive passive motion. — Ed.] 



ASCENDING ROOT NEURITIS FOLLOWING 
AMPUTATION OF THE CAUDA EQUINA 
CLOSE TO THE CONUS 



rasTORY 

Dr. Murphy (June i8, 19 14): This history was written in 
November, 19 13, before the patient was operated the first time, 
and can be found on p. 355, of the Clinics for April, 1914. 

COMMENTS AND OPERATION 

Dr. Murphy (showing picture on p. 361 of the Clinics for 
April, 1 9 14): That is the colored drawing of the condition as we 
foimd it at operation. The color is not exaggerated. It was 
a fiery red, extending up the nerve-tnmks clear to the cauda. 
The patient has had practically no relief from his pain as a re- 
sult of our previous operation. At first we thought he had some 
relief, but his complaints and his demand for anodynes are now 
as vigorous as before the operation. Whether his complaint of 
pain is due to his drug habit or whether it is due to the continu- 
ance of his neuritis we do not know; but we feel that he should 
be given the benefit of the doubt, and that a fresh attempt should 
be made to give him relief. Dr. Mix, who examined the patient 
originally, has gone over the case again, and will discuss its 
neurologic phases while I am reopening the spinal canal and 
exposing the cauda. 

Dr. Mix: The foremost fact in regard to this patient's case 
is that immediately following the amputation of his right thigh 
he began having pain referred to the amputated foot. In other 
words, the pain began to be felt in the amputated foot within a 
period of time not sufficiently long for the formation of a neurogli- 
oma at the end of the sciatic nerve. The pain began after the 
original operation, — ^within ten days' time,— and this very fact 
VOL. m — 4-'; 705 



7o6 CLINICS OF JOHN B. MURPHY 

indicates that there was some etiologic factor other than a neu- 
roglioma. 

The second important fact is that the pain was located in 
both the internal saphenous territory and in the anterior tibial, 
musculocutaneous, and external and internal plantar territories. 
Some of the severest pain which he felt was along the inner margin 
of the great toe, which surface is supplied by the internal saphen- 
ous branch of the anterior crural nerve. Those filaments in the 
internal saphenous which go to the inner margin of the great toe 
come from the lowermost roots of the lumbar plexus, entering 
the anterior crural nerve, namely, the fourth lumbar root. In 
addition to this pain along the inner margin of the great toe, 
he had a good deal of pain along the outer side of the little toe, 
in the territory of supply of the external saphenous nerve, which 
originates from the posterior tibial and the conmiunicans peronei. 
There was also pain in the web between his first and second toes, 
which territory is supplied by the anterior tibial nerve. Pain 
also occurred over the musculocutaneous supply of the foot and 
toes, and on the sole of the foot over both the internal and external 
plantar territory. Bearing in mind these facts, it is perfectly 
evident that his original pain could not have been caused by a 
neuroglioma on the end of his amputated sciatic nerve, because 
he also had pain in territory not supplied by the sciatic nerve. 

When the patient first came to the hospital, he told us that 
twice the end of his sciatic nerve had been cut off in order to do 
away with the pain in his foot. Had the fact of pain along the 
inner margin of his great toe, permanent in his case, been given 
due importance, it would have been recognized that he had 
trouble in the anterior crural territory from the lumbar region, as 
well as in the sciatic territory from the sacral region. 

If the pain which he had could not be accounted for on the 
hypothesis of a neuroglioma, how could it be accounted for, 
coming on as it did within ten days after the amputation? It 
seems possible that there might have been an ascending neuritis 
following the amputation, involving both the sacral and lumbar 
roots, and this had to be thought of if a diagnosis were to be 
made. It seemed most likely before the operation last December 



ASCENDING ROOT NEURITIS 707 

that an ascending neuritis following the amputation was the cause 
of his trouble, and we, therefore, made that diagnosis. At the 
time of the operation we were rewarded by finding a very marked 
congestion and irritation of the right side of the cauda equina. 

He has now returned to the hospital, because his pain still 
exists. There seems to have been some relief because, at the 
present time, although he has some pain along the inner margin 
of his great toe, it is much less than it used to be. He still has 
pain in the territory of the musculocutaneous nerve and in the 
territory of the external saphenous and the internal and external 
plantar nerves. It seems wise to open the spinal canal once 
more, this time in the region of the twelfth dorsal and first lumbar 
vertebrae, and to cut the nerve-roots just as they pass out of the 
side of the cord. If they are divided close to the cord, every 
trace of pain should be obliterated in this patient's case. When 
you cut one of these sensory roots entering the spinal cord, you 
are sure of a complete degeneration. If the nerve is cut on the 
side distal to the ganglion, you do not necessarily have a cure, 
because you are leaving intact in the ganglion the cell-body of the 
nerve-fiber. All that you do in severing the nerve-trunk distal 
to the ganglion is to cut off the nerve-fiber from the cell-body. 
If, however, the nerve is cut between the ganglion and the cord, 
there can be no possible regeneration because the cell-body in the 
posterior spinal ganglion will die. 

There is perhaps another explanation for this man's pain. 
It is a fact that an ascending neuritis such as his may have in- 
volved the cord, and that we are having myelitic symptoms pro- 
ducing the pain rather than root symptoms. Furthermore, 
there is a possibility that this man's pain is in his head at the 
present time, rather than in his foot. We know that he has used 
opium in various forms for the control of the pain in his foot. 
If on exposing the lower portion of the cord the nerves can be 
completely divided on the right side, and if after that the pain 
should still persist, we shall have positive proof that he is feel- 
ing something which he cannot actually feel : that the morphin 
has got the best of him. It was in order to relieve the patient 



yo8 CLINICS OF JOHN B. MURPHY 

from the pain which he says he has and to give him the benefit 
of the doubt that this laminectomy is again advised. 

Dr. Murphy: Since all this patient's spinous processes have 
been removed over the area which we wish to expose, we must 
make our opening into the canal by attacking the vertebral 
process next above our previous operative defect, which is the 
twelfth dorsal. Then, when we have opened the dura at this 
level, we shall split it from above downward, because, as all the 
usual landmarks are entirely gone, we might otherwise do the 
Cauda a serious injury by cutting into it unexpectedly. 

An important point in this case is that, according to our 
knowledge of the anatomy of the cauda and of the degeneration 
of nerves, he should have no return of the pain in the leg follow- 
ing division of the affected half of his cauda. Sensation as well 
as motion should have disappeared. He should have an ascend- 
ing degeneration of all the sensory filaments from his leg, because 
they have been cut between the sensory ganglia, which are 
situated just inside the spinal foramina and the spinal cord. 
The motor filaments were divided at the same time as the sensory 
filaments in the cauda, but the motor axons can regenerate be- 
cause their nutrient cell-bodies in the anterior horn of the spinal 
cord can send out a fresh axon, as these motor axons are all pro- 
vided with a neurilemma when they leave the spinal cord and 
are, therefore, capable of regeneration. The central sensory 
axons, however, the cell-bodies of which are located in the spinal 
ganglion, are provided with a neurilemma for only the short 
distance from the ganglion to the cord : and lose their neurilemma 
when they enter the cord to ascend in the columns of Goll and 
Burdach: they, therefore, cannot regenerate. We have all 
accepted that belief in connection with the neuralgias of the fifth 
pair of cranial nerves, the trifacial, the nerves on which sensory 
root division or evulsion (Frazier), because of inveterate pain, is 
most frequently practised. The outlook in the neuralgias due to 
an ascending neuritis is much more unfavorable than in the neural- 
gias without an accompanymg inflammation. We know that 
once they start to recur after operation, they are prone to con- 
tinue until the death of the patient. We know the pain recurs 



ASCENDING ROOT NEURITIS 709 

in such cases not only after division of the nerve, but also after 
division of the spinal cord itself. It may be that the neuritis, 
in following the axons upward, invades the cord and becomes a 
myehtis. But this does not necessarily become a diffuse myehtis, 
because the symptoms may remain purely sensory and the motor 
elements not become involved — at least, not until very late in 
the process. What the nature of the infection is which produces 
this ascending inflammation we do not know. Of course, it 
may not be a microorganism which produces the trouble, but a 
toxin, and we do actually know that the tetanus toxin follows 
up the nerves and reaches the central nervous system by this 
route. [Demonstrates the filaments of the cauda which have 
now been exposed.] The motor filaments in the cauda may have 
nearly regenerated now because almost six months have elapsed 
since their division. The regeneration is not yet complete, 
however, because he has not regained any of the motion he lost 
after the operation. 

The redness of the inflamed filaments on the right side of the 
cauda which we noted at the last operation and had pictured 
for the Clinics is still present. Note the difference in color 
between the two halves of this cauda. The filaments on the 
right side are purple, and those on the left, white. The color of 
the filaments on the right side is now a deep purple, whereas at 
the previous operation it was a fiery red. That fact may indi- 
cate that the inflammation is now in a less acute stage than at 
the former operation. The right half of the cord also appears to 
be somewhat atrophied, just as we should expect six months 
after its caudal division. At the lower end of the old woimd the 
laminai of one vertebra have redeveloped clear across the opera- 
tive gap, and completely close in the cord from above. In the 
course of time bone might have regenerated across the entire 
field of our previous exposure of the cord. 

We shall redivide all the filaments on the right side of the 
Cauda close to the spinal cord. Before doing so we shall first 
try the f aradic current on the filaments and see if any of the motor 
axons have regenerated. [Applies current.] None of the pa- 
tient's muscles twitch, and, therefore, we must conclude that none 



7IO CLINICS OF JOHN B. MURPHY 

of the motor axons have regenerated, or, at least, have completed 
their regeneration as yet. 

Let the record show that we divided all the filaments of the 
Cauda on the right side of the conus close to the spinal cord. 

Let the record show that we exposed the cauda equina and 
the conus, and that all the fibers coming into the conus on the 
right side were purple red in color, whereas at the previous 
operation they were fiery red, showing the neuritis to be still 
active; that all these red filaments were divided close to the 
conus; that the faradic test of the filaments on the right side 
gave no muscular response, showing that there has been no re- 
generation of the motor axons in the right half of the cauda which 
were divided in the previous operation; and that there should, 
therefore, be no regeneration of the central sensory fibers, thus 
bringing us to the conclusion that his pain is of central, not per- 
ipheral, origin. 

[Complete primary union. Pain was frequent and referred 
to different portions of the amputated extremity, but is now 
gradually abating (July ii, 1914). Temperature normal. He 
has complete voluntary control of both vesical and anal sphinc- 
ters. — Ed.] 



MALIGNANT PAPILLOMATOUS CYST OF THE 
BREAST.— DIFFERENTIAL DIAGNOSIS.— 
OPERATION 



HISTORY 

The patient is a woman aged forty-six years. Her family 
history is negative for tuberculosis. Her mother died from a 
tumor of the chest, thought to be a sarcoma of the rib, which de- 
veloped after a fall. 

Twelve years ago, in 1902, the patient first noticed a sKght 
milky discharge coming from the nipple of the left breast. This 
discharge came, she says, just as milk would come when she was 
nursing her children, and amounted to about one-half a dram per 
day. The discharge continued and became bloody in character 
during the following year, so that she had to wear cloths to pro- 
tect her garments. In the year 191 2 she first noticed a small, 
hard nodule, about i^ inches in diameter, directly above the 
left nipple. About the same time the discharge from the breast 
gradually disappeared. The ttmior has steadily grown until 
it is now about the size and shape of a hen's egg, and is freely 
movable on the deeper structures. The skin is freely movable 
over it. The growth, situated just behind the nipple, and ex- 
tending a little more to the left than to the right side of the nipple, 
is woody in consistence, but not tender. The patient says she 
often has sharp, stabbing pains in the breast. She can recall no 
injury or infection of the breast. The axillary glands are not 
palpable. She has lost no weight since the timior was noticed 
two years ago. 

COMMENTS AND OPERATION 
Dr. Murphy (April 8, 1914) : When the patient came to me 
she had a large, nodular, infiltrated mass just above the nipple. 
I could detect a difference in the resistance between the upper 

711 



712 CLINICS OF JOHN B. MURPHY 

and lower portions, and I diagnosed the tumor as a cyst. I im- 
mediately aspirated the tumor with a hypodermic syringe, as I 
always do in these cases, whether I diagnose a cyst or not, and, 
using the smallest hypodermic needle, I brought out several 
drams of bloody fluid from one focus, and some clear fluid from 
another, showing there were multiple cavities. The major part 
of the tumor thereupon melted away and disappeared, but there 
was still left a hard mass above the nipple. 

All these cysts of the breast, if tense, feel like soUd tiunors 
imtil you puncture them; but you should never feel that your 
diagnosis is complete without puncturing them. This is the 
fourth case of this kind we have had from the opposite margins 
of the Continent, all with the diagnosis of carcinoma. You can 
imagine the mental suffering on the part of the patients in all 
these trips, believing these tumors to be malignant, while they 
are just cysts. These are oversights in diagnosis which are 
easily avoidable; but when you come to differentiate between an 
adenoma and a carcinoma, you cannot make the differentiation 
so easily. The patient with an adenoma or a cyst, of course, 
has no scaling of the nipple, such as comes with a Paget's cancer. 

On examining the involvement in this patient you find that 
the major portion of the cyst has disappeared since the puncture. 
We punctured the cyst and then changed the direction of the 
needle, putting in a fresh one. The nipple is fixed to the skin 
and retracted in a manner not typical for a Paget's cancer. There 
is no enlargement of the axillary or cervical glands, which are 
accessible to palpation, but there is a bloody fluid in the cyst. 
A bloody fluid in a cyst of the breast is suspicious of two things — 
either a carcinoma or a villous growth within the cyst, with 
hemorrhagic tendencies. 

We shall remove the whole breast. I must first study the 
configuration of this breast, so as to make the proper incision in 
the skin. Never bevel the skin in cutting it, and make the skin- 
flap thin, since the skin lives much better when it is thin than 
when it is thickly padded with fat. Now I am down to the 
aponeurosis of the pectoralis major. We always remove this 
Hxmeurosis, but we do not excise the pectoral muscles in our 



i^Bfe* 




Fig. 229. — Photograph of excised breast containing a cystadenoma papilliferum- 
probably malignant — near the nipple. 



713 



MALIGNANT PAPILLOMATOUS CYST OF THE BREAST 715 

cancer operation, because the malignant cells pass through the 
lymphatics in the aponeurosis of the muscle and not through the 
muscle itself. We have determined that this breast must go, 
and we are removing it without pressure and without manipula- 
tion, so as not to loosen malignant cells, if they be present, and 
force them into the circulation. 

[Completion of the removal of the breast.] 

I shall open this breast now that I have excised it, and de- 
termine whether to go into the axilla or not. There is the hemor- 
rhagic cyst which has not yet been opened. [Incision of cyst.] 
There is the lining of the cyst. There is the villous growth in 
the cyst. Is not that pretty? There is always a why for the 
wherefore, if you hunt hard enough for it. That papilloma ac- 
counts for the blood. I am now cutting through the more com- 
pact portion of this tumor. Here is a neoplasm which looks 
peculiar and suspicious, encapsulated, but of a pecuhar color. 
It looks, perhaps, more like a sarcoma than a carcinoma. Can 
you see that papilloma? That accounts for the fact that she has 
been bleeding from the nipple all these years. It is beautiful 
and fits in nicely with the clinical history. [Demonstrates the 
specimen to the clinic] There is the papilloma in the base of the 
cyst. The upper portion of the specimen with the clot is the 
under portion of the neoplasm. I want the pathologist to spKt 
this tumor through the base. There, as I split the papilloma, 
you get a good view of the solid neoplasm at its base. The solid 
growth looks very suspicious of malignancy. The condition 
does not look like a virulent malignancy, but I shall take out the 
axillary lymphatic glands nevertheless. She has been bleeding 
about twelve years. The diagnosis of a carcinoma simplex would 
not fit in with that long period of duration. 

[The breast and axillary glands and fat were removed after 
Dr. Murphy's usual procedure, retaining the pectoralis major and 
minor to fill the axillary space, as described in the Clinics for 
April, 1 9 14.] 

For about twelve years we have retained the pectoralis major 
in our breast operations. For a time we did the Halsted opera- 
tion, but we finally abandoned it. We do not remove either of 



yi6 CLINICS OF JOHN B. MURPHY 

the pectoral muscles now. One of the reasons we do not remove 
the pectoral muscles is because Bryant, in an experience extending 
over something like forty years, saw a recurrence in the pectoral 
muscles only once. The lymphatics run on the surface of the 
muscles, but not in the muscles themselves. Therefore we con- 
clude that by taking out the fascia of the muscles and the lym- 
phatic-bearing tissue between the pectoralis major and minor, 
we take out everything which is necessary for the patient's ulti- 
mate safety, and yet keep the pectoralis major and minor to 
protect the axillary vessels and nerves from pressure. In 
Greenough's splendid paper at the Cleveland meeting of the 
American Surgical Society he analyzed all the cases that were 
operated in the Massachusetts General Hospital for a period of 
twenty-five years. He covered all the states adjacent to Massa- 
chusetts by collecting personal communications from the sur- 
geons or interviewing the patients, and foimd that thirty-odd 
per cent, of all the cases after operation had edema of the arm. 
Think of it! One-third of them had edema of the arm! We 
know the Massachusetts General Hospital has about as good 
surgeons as any hospital in the country. Edema of the arm 
means incapacity for the patient and more or less pain. These 
patients, according to our experience, do not have these neural- 
gias, nor the edema, if you keep the vessels and nerves covered 
up with the pectoral muscles. It was believed for a long time 
that it was an obstruction to the lymphatic return that produced 
the edema, while in fact it is the obstruction to the venous return. 
We know now, as a practical fact, that if you take out the muscles, 
you get edema, whereas you do not get it if you do not take the 
muscles out. 

If you do not put something in the axillary space, you must 
dress the arm at right angles. Hawarden took up this matter 
of dressing the arm at right angles in a hyperabducted position 
in order to make the skin-flap lie close to the chest and lessen 
the subsequent connective-tissue formation. If you do not 
obliterate this space, it will fill up with connective itssue. First, 
there will be a hematoma, which will clot and finally organize, 
with the formation of connective tissue. 



MALIGNANT PAPILLOMATOUS CYST OF THE BREAST 717 

Let the record show: First, that we made the skin incision, 
being careful not to bevel the skin. Then we elevated the pec- 
toralis major muscle and took off the breast from above down- 
ward. We divided the lymphatic connection with the axilla 
early, so as to prevent the distant transmission of malignant 
cells during the unavoidable manipulation of the breast. After 
taking off the breast we then cut away the remaining portion of 
the aponeurosis of the pectoralis major; separated the pectoralis 
major from the pectoralis minor; divided the costal attachment 
of the pectoralis major, and threw the muscle outward. Then 
dissected off the aponeurosis between the pectoralis major and 
minor and divided the costal attachments of the pectoralis minor 
and threw it outward. Then we started the axillary dissection 
at the apex of the axilla, just at the lower border of the clavicle. 
With a sponge we wiped the fatty tissue, bearing the glands, 
off the vessels. You often find an infected gland attached di- 
rectly to the vein. By wiping off such glands with gauze you 
often can get them away without tearing the vein. If the vein 
should tear, put on a forceps and then top-sew the tear; that 
procedure suffices. At the lower and posterior margin of the 
axilla you come upon the subscapular nerves, the long and the 
short, and you must always watch for them, preserving them care- 
fully, because they innervate the latissimus dorsi muscle, which 
is the one the woman uses in dressing. Then fully close the gap 
in the axilla with the two pectoral muscles. 

This operation is rapidly done and gives just as good results 
as the Halsted operation, besides leaving a much better looking 
chest. If a woman sees her neighbor's breast after a typical 
Halsted operation, she will hide her cancer until its development 
is hopelessly far advanced. You will hear patients say again 
and again, ^'I saw Mrs. Smith's breast and I always said if I 
had a cancer, no one should know it, because I had rather die 
than have my breast look like Mrs. Smith's." 

With the operation which we have just performed there is no 
deformity in the axilla, and so little on the chest that it does not 
frighten the prospective patient. This method is the most de- 
sirable operation, so long as we can retain the muscle without 



7l8 CLINICS OF JOHN B. MUEPHY 

additional danger to the patient. In all my experience I have 
had only one return in the muscle, and that was a case of deep- 
seated carcinoma where I should have taken out the pectoral 
muscles. Where the cancer has penetrated through the posterior 
wall of the manomary gland into the pectoral muscles, then we 
always take out the muscles. Along the line of transmission of 
the tumor we always take out the fascia in both groups of cases 
and always clean out the axilla. After all is said, I am not very 
enthusiastic about the operative removal of carcinomata of the 
breast, not so much on account of the recurrences in loco, as be- 
cause of the metastases in distant organs. 

The pathologist reports that the tumor in the cyst is a papil- 
loma. That, I believe, is correct. He says that the tumor at 
the base of that papilloma is probably malignant. That report 
helps to clear up the situation. It was fortunate that I cleaned 
out the axilla. The microscopic findings were just what I thought 
they would be, and fit in exactly with the gross appearance of the 
specimen. That history was a beautiful one, because it dovetails 
so nicely with the clinical and pathologic findings. 

[Pathologist's report {Dr. Zeit): The specimen removed from 
the breast at operation gives the gross and microscopic appear- 
ance of a chronic cystic mastitis. A single large cyst near the 
nipple contains a cystadenoma papilliferum, probably malignant. 

Note. — ^The wound healed by complete primary union. 
There were no postoperative complications whatsoever. The 
patient left the hospital April i8, 19 14, completely recovered. 
She had no swelling of the arm at any time, and before going 
home was able to raise her hand high enough to dress her hair. — 
Ed.] 



PARALYTIC ILEUS FROM CRYPTOGENIC 
PERITONITIS 



fflSTORY 

The patient, a married woman, forty years of age, entered the 
hospital April 30, 19 14, with the following history: 

She has five children, living and well. She has had five mis- 
carriages. Her husband died of a tumor of the liver. Menstrua- 
tion, which began at twelve years of age, has always been regular, 
of the twenty-eight-day type, five days in duration, two to three 
napkins being used daily. It has become more painful in the 
past year, the pains being referred to the center of the hypo- 
gastrium. The amount of her flow has not increased, nor has 
there been any intermenstrual flow or vaginal discharge. 

The patient states that for the past year she has constantly 
felt tired. She thinks she has been growing progressively weaker. 
She has also become somewhat sallow. Since October, 19 13 
(eight months ago), she has noticed some tenderness over the 
whole of the lower abdomen, but especially marked in the left 
iliac fossa. In December, 1913, she was taken with a severe, 
cramp-like pain in that region. This pain lasted two days. 
During this time she vomited continuously and her bowels did 
not move. She does not remember any chills, but did have fever. 

She recovered from this attack, but the tenderness in her lower 
abdomen increased. She has been stubbornly constipated since 
October, 1913. At first cathartics relieved her, but for the past 
six months only repeated enemas have been successful. On two 
or three occasions she has passed small amounts of dark-red, 
clotted blood from the rectum. This bleeding occurred after 
straining at stool. 

On Tuesday morning, April 28, 1914, she was taken with 
severe, cramp-Uke abdominal pains, which continued during the 

719 



720 CLINICS OF JOHN B. MURPHY 

day, and radiated through all her lower abdomen. At 3 p. M. 
she vomited. There was no blood in the emesis. About the 
same time she became very tender over the left iliac fossa. She 
thinks she had a chill; she states positively that she had fever 
of 101° or 102° F. about five hours after the onset of the pain. 
On Wednesday morning, April 29th, she was given an oil enema 
and had a scanty bowel movement, with a bad odor to the stool. 
She did not notice its color. The bowel movements had never 
caused any increase in the abdominal pain or tenderness in this 
attack, or in the previous attacks, except on severe straining. 
She has belched a great deal for the past year. She never has 
vomited any blood, and never has had any sudden attacks of 
fainting. She has lost a little weight, but then she has not eaten 
much of late. The patient attributes her last attack of cramps 
to the eating of green onions, Tuesday noon, just prior to the onset 
of the pain. She has never had any urinary symptoms. She 
has never been jaundiced, and never has had the pains radiate 
into the thighs or groins. 

Vaginal examination on admission to the hospital shows a 
mass, apparently attached to the wall of the sigmoid, but not 
occluding the lumen of the bowel. 

Palpation shows tenderness and rigidity over the whole of the 
abdomen. Her point of greatest tenderness is over the left iliac 
fossa, where a mass can be felt lying low down in the pelvis. 

Her white blood count is 51,000, and her hemoglobin is be- 
tween 50 and 60 per cent. 

A vaginal examination, made on May 4, 19 14, is recorded as 
follows: A mass in the rectum or sigmoid cannot be felt; the 
uterus is movable. The cervix is enlarged; there is a laceraton 
on its left side. Inspection of the vagina, cervix, and rectum re- 
vealed no further pathologic changes. Menstruation is nearly 
due. 

COMMENTS AND OPERATION 

Dr. Murphy (May 6, 1914): She never has had that sign 
which is so characteristic of a malignant neophism of the lower 
bowd — the passage of slime and blood, unaccompanied by feces. 



PARALYTIC ILEUS FROM CRYPTOGENIC PERITONITIS 72 1 

The history is peculiar. With two of these attacks of ab- 
dominal cramps she has had an elevation of temperature, and 
with one she had a chill. With the evidences of an infection she 
has had the train of symptoms of an ileus — pain, nausea and 
vomiting, abdominal distention, and inabiKty to secure a copious 
bowel movement by the ordinary means. That she has had with 
it an elevation of temperature means that it is not a true mechani- 
cal obstruction; that there is some associated lesion other than 
a mechanical hindrance to the advancement of the feces. In 
view of the fact that obstipation has not been complete, that 
rigidity and tenderness are present over the entire abdomen, 
and that she has the unmistakable evidences of a severe infection, 
it is quite likely that the patient has some degree of peritonitis, 
and that, in consequence, inflammatory paralysis of the intestine 
may be a considerable factor in her failure to secure bowel move- 
ments. We have not been able to demonstrate any free fluid in 
the abdomen. 

She is decidedly sallow. There is at present no tumor pal- 
pable on either vaginal or abdominal examination. She has had 
an area of increased resistance to palpation in the left iliac fossa. 
This resistance was most marked during the attack of cramps. 
When the attack subsided, the soreness in the lower abdomen still 
persisted, particularly on the left side. She improved for a couple 
of days after we succeeded in producing a bowel movement, but 
now she has another attack. When she was admitted to the 
hospital she had a temperature of 103° F. The temperature 
returned to normal when we succeeded in moving her bowels. 
Now it has gone up again. That is why we think she has some 
infection associated with her obstruction. 

Of the lesions simulating ileus, the most common one which 
causes fever is, of course, appendicitis, and the next most common 
an inflammation of the Fallopian tubes. This patient has no 
local manifestation of tubal trouble. Vaginal examination re- 
veals nothing of significance. She has not had the typical mani- 
festations of recurring appendicitis. The acute attacks have not 
had the characteristic onset or the local signs of an appendicitis. 
Moreover, the pains have been cramp-like. Carcinoma of the 
VOL. m— 46 



722 CLINICS OF JOHN B. MURPHY 

cecum might occur in a patient of this age and produce an ob- 
turation ileus, but it is not associated with fever, as a rule, unless 
accompanied by ulceration or abscess formation. A chronic 
tuberculosis of the cecimi or sigmoid with acute exacerbations 
might also be considered, but they are on the right side. Whether 
the tuberculous ulcers lie chiefly in the lower ileum and cecum 
or in the sigmoid does not seem to make much difference in the 
symptoms. Tuberculous colitis of the recurrent or progressive 
type is associated with elevations of temperature and often with 
chills. Blood, more or less mixed with mucus and pus, is found 
in the stools. A Gram stain of these particles of pus or mucus 
reveals a great predominance of Gram-positive organisms, 
chiefly cocci. A careful search often reveals the presence of 
tubercle bacilli, even without guinea-pig inoculation. In this 
case the examination of the stools has been negative. 

A parasigmoid sinus may give a somewhat similar train of 
symptoms — a chill, an elevation of temperature, a leukocytosis, 
and a peritonitis. It produces a cHnical picture on the left side 
very closely resembling what appendicitis produces on the right 
side. She has no evidence of an infection starting in the gall- 
bladder except her sallow complexion. She had an amputation 
of the tliigh some years ago, which was associated with a very 
severe sepsis. 

Dr. Mix has examined this patient, and while I am exploring 
the patient's abdomen, he will discuss the medical aspect of the 
case with you. 

Dr. Mix: The salient points of the history as she gave it 
to me, for I understand she has given three quite different his- 
tories, are that in April, 1913, or at least some time in the spring 
of the year 1913, because she cannot remember the exact date, 
she was suddenly seized with severe, cramp-like pains which 
spread upward from the lower abdomen. These were associated 
with headache and vomiting. The vomiting lasted for about 
three hours' time and then stopped. Following this attack, 
there was some constipation for a week or so. She has been more 
or less constipated all the time since, but she attributed the consti- 
pation to the fact that because of the loss of her thigh she had 



PARALYTIC ILEUS FROM CRYPTOGENIC PERITONITIS 723 

to sit a good deal and has not been so active as she formerly 

was. 

One year later, that is, in April, 19 14, with a period of normal 
health intervening between the first attack and the present one, 
she was taken with another seizure exactly like the first, only 
more severe. With this attack, which began, as nearly as she 
can remember, at 2 a. m. on Wednesday, April 29, 19 14, "the 
pain became very much in earnest," as she expressed it. During 
the previous day, April 28, she had been having not occasional 
but steady pains all over the lower abdomen. She had had pains 
similar to these on previous occasions and they always went 
away. She expected that this pain would go away as usual, 
but at 2 A. M. it began to be very severe, and at 7 A. M. she began 
to vomit. She vomited all day Wednesday, April 29, and also 
the following morning. Since Thursday of last week she has not 
vomited. During the initial period of the pain she had several 
movements of the bowels. Every time she took a sip of water 
and every time she vomited she also had a bowel movement. 
She said the pain was all over the abdomen, but was for the most 
part concentrated in the center to the left, in the iliac fossa, not 
down in the pelvis. 

Now the lesions which might occur are munerous, of course, 
but we must consider for this particular case a lesion which is 
associated with fever, because on both of these occasions when she 
had this pain she had a temperature above normal. On the last 
occasion her temperature reached 103° F. Moreover, though we 
have no information as to her former attack, she had a leukocyte 
count when she entered the hospital of 51,600. This later fell 
to 31,000, showing the enormous leukocytic response apparently 
to an infection — apparently an infection because of the tempera- 
ture and the leukocyte count. A neoplasm would not give rise 
to so high a leukocytosis. An abscess or a peritonitis might 
easily account for both the temperature and the leukocyte count, 
but an abscess is not Hkely, in view of the fact that there were 
two similar seizures one year apart. 

There is another element in her case, a mild degree of cachexia, 
though she has not lost much weight during the past year — 



y24 CLINICS OF JOHN B. MURPHY 

only eight pounds. Still her color is not good. When one looks 
at her one feels that she is very sick. 

The possibility of a malignant neoplasm being present must 
be entertained, although the fact that there have been two 
separate seizures, separated by an interval of a year, does not 
make the possibility of there being a malignant neoplasm very 
certain. Nevertheless, a leukocytosis may sometimes be ex- 
plained by the presence of a sarcoma, or an ulcerating carci- 
noma. 

However, because of the present difficulty we must also as- 
sume that it is a case which is capable of giving rise to an obstruc- 
tion at times with an excess of peristalsis occurring at the be- 
ginning of the obstruction. The excess of peristalsis rather 
obliterates the possibility of a paralytic ileus as the cause of the 
obstruction. 

There is a slight possibility that the case is one of visceral 
lues. Her husband died of a tumor of the hver, concerning which 
we have no information. It may have been a carcinoma or it 
may have been luetic in origin. Her obstetric history shows that 
she had three normal children, then a miscarriage, then another 
child that lived, then a miscarriage, then a child that died, then 
three miscarriages. Of the last seven pregnancies, there is but 
one living child. Of the five miscarriages, three were induced, 
so that we have no actual information as to the possibility of a 
luetic origin except the possible inference that something inter- 
fered with the health of the later offspring. A luetin test has 
been made and is negative. 

The possibility of the case being tuberculous does not seem 
very certain because of the long period of quiescence — one year. 
We expect a tuberculous process to be insidious in onset, not to 
have excessively stormy periods, or a development of symptoms 
with such extreme suddenness as the pain in the two attacks which 
this patient has had. 

The fact is that the diagnosis cannot be made. The high 
leukocytic count would lead one to suspect an inflammation of the 
peritoneum or the presence of an abscess somewhere in the ab- 
dominal cavity. On the other hand, the symptomatology is 



PARALYTIC ILEUS FROM CRYPTOGENIC PERITONITIS 725 

merely that of an obstruction to the bowel. Physical examina- 
tion discloses no tumor which can satisfactorily account for the 
obstruction. It is, therefore, necessary to do an exploratory 
laparotomy. The x-rsiy shows great accumulations of gas, as 
you see, on the left side of the abdomen. All these dark- 
colored spots are evidently pockets of gas which has been unable 
to make its way to the rectum. The possibility of its being a 
parasigmoidal sinus appears remote, because of the interval of 
a year which has elapsed between the two seizures. The possi- 
bility of adhesions being the cause of the obstruction is possible, 
adhesions without any etiologic history being very common in 
the abdomen. However, adhesions in themselves cannot ac- 
count for the leukocytic count and the temperature, which latter 
symptom seems best explained on the basis of a secondary peri- 
toneal inflammation. 

Dr. Murphy: Let the record show that on exposing the peri- 
toneum we find it exceedingly congested throughout; it has lost 
its glistening appearance, and shows many flakes of fibrin, but 
no collection of free fluid in the pelvis or elsewhere; that there is 
no distention at all of the lower bowel; that there is no tumor in 
the upper rectum or in the iliac fossa; that the entire large in- 
testine is free from mechanical obstruction; that there are 
acute, inflammatory agglutinations between the intestinal loops 
everywhere in the abdomen. 

At first glance I thought that this peritonitis might be a case 
of tuberculosis, but it now appears to be more of an acute in- 
flammatory condition. Moreover, there is no evidence of tu- 
berculous involvement of the tubes, which one finds so frequently 
in tuberculous peritonitis. The small intestine is agglutinated 
to the anterior abdominal wall, but the adhesions are fibrinous, 
not fibrous. Organization of them has not yet had time to occur. 
Some of the agglutinated coils of intestine are somewhat distended 
with gas. 

We have made a tuberculin test on her, but she had less fever 
after the injection than she had before it. Of course, a tuberculin 
test made during a period of fever does not have much diagnostic 
significance one way or the other. 



726 CLINICS OF JOHN B. MURPHY 

Both kidneys present nothing abnormal on palpation. I 
nowhere find anything resembling tubercles on the surface of the 
peritoneum, nor any nodules, scars, or evidences of ulceration in 
the intestine. The mesenteric and retroperitoneal lymph-glands 
show no particular enlargement. The appendix shows no evi- 
dence of disease. There are no nodules in the liver, it is not en- 
larged, and its capsule is not thickened. 

We are making cultures from the fibrinous exudate on the 
intestines, and shall report to you later our bacteriologist's 
findings. 

There is nothing to indicate that this peritoneal infection came 
from the tubes. The tubes are perfectly free from macroscopic 
pathology. I am coming to the conviction that we are dealing 
here with a hematogenous infection of the peritoneum. There 
is no accumulation of pus anywhere in the abdomen — only the 
fibrinous agglutinations everywhere. When I was an intern 
in the Cook County Hospital we used to see types of peritonitis 
similar to this in connection with puerperal infections, and with- 
out any evidence of perforation of a viscus. This reddened and 
congested peritoneum looks almost blistered in spots. It would 
not be far out of the way to say that this inflammation resembles 
an erysipelas of the peritoneum. I am gratified at the way the 
case has turned out, for I was fearful that this might be a car- 
cinomatous peritonitis, or a peritonitis going out from the per- 
foration of a colon carcinoma, although she did not have the car- 
dinal symptom of a cancer of the lower intestine, namely, the 
passage of blood and mucus, with and without the passage of 
feces. I feared that the intern and patient might possibly have 
overlooked an occasional small amount of blood and mucus in the 
passages. 

The high leukocytosis, 51,600, speaks against a tuberculous 
peritonitis. The agglutinations, also, are more diffuse than 
they usually are in tuberculosis, and there are not those cobweb- 
like adhesions present which we often find in great amount in a 
tuberculous inflammation of the peritoneum. I believe that we 
have to deal here with a hematogenous peritonitis of the type 
which !<Tminatcd fatally in the boy we showed here in clinic the 



PARALYTIC ILEUS FROM CRYPTOGENIC PERITONITIS 727 

other day, except that the infection here is not so virulent, nor 
the inflammation so foudroyant as in the boy's case. This boy's 
acute peritonitis was preceded by nausea, chills, sore throat, 
and the development of a phlyctenular tonsillitis, with patches 
of pseudomembrane on the tonsillar surface, but without the 
presence of the Bacillus diphthericB. He then developed the 
signs of a general peritonitis, without any evidence of free fluid 
or of perforation of a viscus. We did not operate on him because 
we considered it a metastatic, hematogenous peritonitis, of throat 
origin, a type of which we had several cases two years ago, 
during the milk-borne epidemic of streptococcus pharyngitis. 
Every one of these cases with a clean-cut history of a preceding 
pharyngitis showed no abdominal focus of perforation, but only 
a diffuse inflammatory infiltration of the peritoneum. Every 
one of these cases we operated died. Therefore we believed it 
useless to operate on this boy, because the operation could ac^ 
compHsh nothing of value, and would only hasten his death. 
He was already cyanotic when he entered the hospital, and as his 
symptoms developed further his cyanosis increased up to the time 
of the fatal termination. There was never any free fluid in the 
abdomen that we could demonstrate by percussion. His ab- 
domen was scaphoid. He was sent to us with a diagnosis of 
acute appendicitis. We did not operate him because we could 
not agree with that opinion. He was taken sick on Wednesday. 
He had a chill, sore throat, and developed a phlyctenular tonsil- 
litis on that day. On Thursday afternoon, twenty-six hours 
after the onset of the sore throat, he began to have pain in his 
right iliac fossa. That pain continued and he was brought in 
here on Friday, twenty-four hours later. His leukocytosis on 
admission was 15,000 approximately. He then had diffuse 
abdominal tenderness and rigidity, without a local mass or free 
fluid, all within forty-eight hours of the onset of his tonsillitis. 
The original metastasis may have been in his appendix beneath 
the serosa, and the infection have spread from there to the rest 
of the peritoneum, or there may have been other peritoneal 
metastases following the initial pharyngeal involvement. In 
two of the cases we operated two years ago during the epidemic 



728 CLINICS OF JOHN B. MURPHY 

we found the appendix just a little more congested than normal, 
without evidence of a perforation. There was no pus anywhere 
in the peritoneal cavities, but they were blistered throughout 
the entire surface, and yet both of these cases went on to a fatal 
termination. One gave a mixed pneumococcus and strepto- 
coccus culture and the other pure streptococcus. This is an 
entirely different type of peritonitis from that which follows a 
perforated but not gangrenous appendix. 

This boy kept growing gradually worse, his constitutional 
symptoms continually increasing, particularly the cyanosis. 
When a patient with intestinal obstruction or peritonitis com- 
mences to become cyanotic, and the nails, lips, ears, and cheeks 
begin to get blue, then look out for trouble. That is the most 
serious of all the symptoms. Temperature and pulse cut but 
little figure in comparison. The cyanosis shows that the heart 
is giving out and that the danger of death is imminent. This 
boy's pulse-rate went up and up imtil it reached 170 and then 
became uncountable. He remained clear mentally to within a 
few minutes of his death, a striking feature which has been fre- 
quently noted in severe streptococcus infections. 

This type of peritoneal infection was relatively frequent be- 
fore the antiseptic era. The older men who saw cases of puerperal 
sepsis in that period can remember that these women had a 
diffuse subperitoneal cellular infection, as revealed at autopsy, 
and were conscious almost to the last minute of life. 

A culture from the throat of this boy showed a pure growth of 
a coccus more like a pneumococcus than a streptococcus. We 
had an autovaccine prepared and administered in eighteen hours, 
but it had no effect on the course of the infection. Remember 
that in vaccine therapy the element of time is a factor. The 
human organism requires a period of time in which to react to 
the vaccine. With a very severe intoxication there is no time 
for such reaction. 

[The abdomen was closed without irrigation or drainage. 
She carried a temperature for weeks after the operation, and de- 
veloped a suppuration in the cellular tissue of the abdominal 
wound which did not interfere with the deep union. She also 



PARALYTIC ILEUS FROM CRYPTOGENIC PERITONITIS 729 

developed a suppuration of the left wrist-joint, which was 
aspirated and responded with a rapid and complete recovery 
upon treatment with one immediate injection of formalin in 
glycerin. She made a slow but good recovery. The cultures 
made from the peritoneal exudate and also from the aspirated 
wrist-joint showed no growth. No anaerobic cultiures were 
made, and, possibly, this may have been the reason for failure 
to secure a growth. The fresh stained smears also showed no 
organisms. — Ed.] 



OLD UNUNITED COLLES' FRACTURE. OPEN 
REDUCTION— NAILING OF THE FRAG- 
MENTS 



HISTORY 

The patient is a married man, aged forty- two, a practising 
physician. On February 14, 19 14, he sHpped and fell sideways, 
striking with his full weight on the palm of his right hand while 
his arm was extended. He says that he felt a stinging sensation 
at the wrist, and upon examining his hand found that the lower 
end of the radius was broken. He called in two other doctors, 
who tried to reduce the fracture, but were unsuccessful. The 
following day, February 15, 1914, he was given an anesthetic 
and another attempt was made to reduce the fracture. An a:-ray 
picture taken at the same time showed the lower end of the radius 
broken. The lower fragment, about one inch long, was displaced 
upward and backward. The upper fragment was displaced to- 
ward the ulna. The ulna seemed sHghtly displaced outward. 
The pain in the wrist continued, and the deformity remained 
about the same as at the time of the accident. Again, on 
February 16, 1914, another anesthetic was given and a third 
attempt was made at reduction. An :i:-ray plate was made 
only of the lateral aspect of the wrist, and doctors said the 
fragment was replaced; but the pain in the wrist and the 
deformity persisted. On February 19, 19 14, he developed a 
phlebitis of the forearm which lasted one week. He had some 
fever at the time, but does not know how much. After the last 
operation the hand and arm were placed in splints, which the 
patient wore for two weeks. 

COMMENTS AND OPERATION 
Dr. Murphy (April 18, 19 14): Note the doctor's statement 
that after every attempt at reduction the pain and discomfort con- 
tinued — after the first effort, after the second, and after the third. 

731 



732 CLINICS OF JOHN B. MURPHY 

In order that we may have a clear understanding of this con- 
dition we must define what a Colles' fracture is. A Colles' 
fracture is a fracture of the lower end of the radius by a force 
impinging upward against the hand and forearm, or by a blow — 
never a fall — on the back of the hand. A Colles' fracture is 
practically always a palmar pressure fracture, never a dorsal 
pressure fracture, just as a Pott's fracture is always a foot ever- 
sion fracture, never a foot inversion fracture. So, the first ques- 
tion is, how did the patient fall to cause the fracture, and the 
second, what happened after the bone broke? In a Colles' 
fracture the radius always breaks from below and in front, up- 
ward and backward. The lower fragment is displaced backward 
upon the upper fragment, and there is usually some angulation, 
which is commonly treated by grasping the hand and pulling, 
a procedure which simply locks the serrated edge of the lower 
fragment in such a way that reduction is impossible. The de- 
sired result was not accomplished here in spite of the efforts of 
the doctor's friends at forcible extension. The patient was 
anesthetized three times, and three times reduction was at- 
tempted, with failure. Why? Because they did not recognize 
the essential factor in the reduction of a Colles' fracture, which 
is not force at all. The essential feature is manipulation: first, 
increase the deformity to make leverage, and then, using this 
leverage, push the lower fragment down. The lower fragment 
then falls forward into place, and if it does not stay forward 
without a support, it is not properly reduced. If the patient is 
kept awake the following night by the pain, the reduction has 
not been properly done. 

The pain and deformity continued after the attempts at re- 
duction. That is the story of the average patient with a Colles' 
fracture. Bear in mind two things: First, you must increase the 
deformity to unlock the two fragments; second, after you have 
unlocked them, the lower fragment falls forward easily by using 
the patient's hand as a lever. The fragment should stay in 
place without support, otherwise the fracture has not been 
properly reduced. 

There is, in addition to the backward luxation, also some 



OLD UNUNITED COLLES FRACTURE 



733 



lateral luxation of the lower fragment of the radius toward the 
radial side, which makes the ulna stick out conspicuously, as 
in this case. The displacement of the lower fragment is toward 
the radial side, never toward the ulnar side, because as the 
shortening takes place the lower end of the ulna makes a pivot 
aroimd which the hand and lower fragment of the radius rotate 
outward. When the reduction is not properly made, the pain 
and suffering occur more frequently than from any other fracture 
in the body. It does not matter whose splint you use if the re- 
duction is correct. Put on a molded posterior plaster-of-Paris 




Fig. 230. — Ancient Colles' fracture. Exposure of the malunited fragments showing 

typical deformity. 



splint covering three-fifths of the circumference of the arm, and 
fasten it in place with adhesive strips. That is all that you need. 
Then, do not commence passive motion early. 

These are unpleasant cases to operate. We make our in- 
cision along the outer border of the radius, expose the radius in 
front and behind, and then separate the fragments and pry them 
into proper position in the way which I shall describe. I want 
you to note that the deformity here, as shown by inspection and 
beautifully in the x-ray, is the classic one for a Colles' fracture. 



734 



CLINICS OF JOHN B. MURPHY 



Why is this patient having pain? Because the lower fragment 
and the callus are impinging on the radial nerve, and because 
the anterior margin of the lower end of the upper fragment is 
pressing constantly against his palmar tendons. That is why 
these patients always have pain until the fracture is properly 
reduced. 

There is the long extensor tendon of the thumb. I am separ- 




Fig. 331. — ^Ancient Colles' fracture. Division of the malunion and prying of 
the lower fragment with the chisel into proper position. 



ating all the soft tissues from the bone, both in front and behind, 
but am leaving the periosteum in place. Now I retract the 
loosened soft parts and expose the entire lower end of the radius. 
This is the usual position of the fragments. There is some radial 
as well as backward luxation of the lower fragment. Here is the 
anterior margin of the lower fragment pressing on the palmar 
tendons. 



OLD UNUNITED COLLES' FRACTURE 



735 



[Inserts the Murphy bone skid between the fragments and 
gradually pries them back into apposition.] 

Now you see that lower fragment is free. It is back far 
enough. You will note that I am careful not to contact to that 
wound any part of the bone skid, or of any other instrument 
which has touched the hand. That is the secret of doing suc- 
cessful bone surgery. Now, I examine the wrist from every 
angle to see that the reduction is complete. The displacement is 




Fig. 232. — Ancient Colles' fracture. Nailing in position of the fragments with a 

wire nail. 



a little overcorrected, if anything, toward the ulnar side. That is 
just what I desire. [Drives a ten-penny nail through the lower 
into the upper fragment, the extra-articular naiHng method, thus 
holding the fragments together in perfect apposition, as shown in 
the x-ray.] We use only one nail, but drive it in in such a way 
that you cannot budge it except by using force. It would take 
20 or 25 pounds' pressure to move the nail. 

Let the record show that the displacement was backward 
and toward the radial side, as indicated by the a;-ray; that after 



736 CLINICS OF JOHN B. MURPHY 

it was adjusted with the bone skid following the separation of the 
impacted fragments one nail was inserted into the radius, reunit- 
ing the fragments in accurate apposition; that the arm was 
dressed in a posterior plaster-of-Paris splint encircling three- 
fifths of the circumference of the arm. 

I am careful not to include in my suture the filament of the 
radial nerve ruiming along the side of the radius, because if I do, 
an area of numbness which is not desirable will be produced in 
the hand. I shall put a couple of stitches in the subcutaneous 
fat, so as to cover the deeper structures and prevent the skin 
from becoming united to them. Just as soon as these stitches are 
in we shall apply the plaster-of-Paris posterior splint, nmning 
from the base of the fingers up to the elbow. Never put a circular 
pressure bandage or a circular cast on the forearm. The stories 
which we could tell of the cases we have seen in this clinic of arms 
ruined by tight bandages and by circular casts, particularly 
after Colles' fracture, are simply appalling. You cannot success- 
fully reduce a fracture by pressure from a bandage or a cast or 
a splint. The penalties for using tight dressings are: First, 
pressure myositis, resulting in Volkmann's contracture; second, 
adhesions of the wrist tendons. The same maxim holds for 
fractures about the elbow. Never put on a bandage with the 
idea that it is going to aid in the reduction. The result will be 
an undesirable one. We have seen three or four dozen cases 
of Volkmann's contracture following such treatment of elbow 
fractures. Remember that a large percentage of these disastrous 
results were the consequences not of the original injury, but of 
the surgery employed. That is what I want to emphasize. 

Now let us consider again the reduction of a Colles' fracture 
as it should be carried out. In the first place, let us recall what 
a Colles' fracture is. It always comes as the sequence of a cer- 
tain type of injury, particularly falling on the palm of the hand, 
and the radius always has its line of fracture directed upward 
and backward. It may break straight across, but is never a 
flexion fracture. It is always an extension fracture and cannot 
be produced by falling on the dorsum of the hand. This doctor's 
radius is broken upward and backward. When the bone breaks 



OLD UNUNITED COLLES' FRACTURE 



737 



this way, the sequence is a posterior luxation of the lower frag- 
ment, as in this case. 

To reduce the fracture, if the patient is not asleep, have him 
seated and stand yourself on the side of the fractured arm. Put 
your distal thumb on the distal fragment of the radius, and your 
proximal thumb on the proximal fragment. [Demonstrates 
on the intern's wrist.] I feel that I could break the doctor's 
radius by the leverage which I thus obtain. That is the same 
type of pressure with which accidents break it. Next I increase 
the deformity, bending the hand and distal fragment dorsally, 
until the upper end of the distal fragment is opposed to the distal 
end of the upper fragment. Then I push the hand and distal 
fragment down, and, while the latter is still at right angles to the 
upper fragment, just let the hand fall forward. If the ends of 
the bone do not stay in proper position, the fracture is not re- 
duced. That is all. If the patient has pain that night sufficient 
to keep him awake, the fracture is not reduced. The common 
method of reduction is to pull and pull. Reduction cannot be 
made successfully that way, no matter how strong you are. 
Remember that this patient was put asleep three times and had 
three men attempt reduction. You can pull so hard that the 
lower fragment will come to lie on a line parallel with the upper 
fragment, but never on the same parallel line. The ends lock 
and cannot be brought into accurate approximation. Then, 
although you put pressure on the fragments, you cannot get them 
back. Remember, the right way is first to increase the de- 
formity and then push the lower fragment down. The procedure 
is carried out almost as easily as it is described. Remember, 
as you push down the lower fragment you swing it to the ulnar 
side. The radial overlapping here in this patient was, I should 
say, one-half an inch or more in extent. 

[The skin wound is now closed with horsehair and without 
drainage and sealed with cotton and collodion.] 

As soon as the collodion is dry, we put on a small dressing and 
the posterior splint. That is all one needs to do. Nature does 
the rest. The nail holds the fragments in position and holds 
them until they unite. 
VOL. m — 47 



738 CLINICS OF JOHN B. MURPHY 

[Demonstrates the photographs and a:-ray plates of another 
patient.] 

Here is the picture of a case of Colles' fracture due to the usual 
trauma (Figs. 233-236). A tight splint was put on. The skin 
ulcerated and left the tendons bare from the pressure of the splint, 
a condition that is absolutely unnecessary. We waited until the 
skin healed, and then we operated on her. You see the limited 
extent to which she could extend her fingers before the opera- 
tion — every one stiff in the same way. She was a harpist of in- 
international reputation and had to make her living by playing, 
so the lack of function in her fingers put her out of commission. 
We elongated each of the tendons, and enabled her to open and 
close her hand. She got a fixation of her tendons from the 
splint pressure, as well as an ischemic myositis. To get rid of 
that fixation, we took a fatty flap from the side of the wrist and 
slipped it in between the tendons. We could have taken the flap 
from the anterior abdominal wall. The flap will live if it is only 
pure fat. If you take muscle and fascia with the fat, its destiny 
is uncertain. 

There is the ic-ray plate of the case we had today (Figs. 
237-240). One can see the lateral luxation, which shows beau- 
tifully, exactly as when we exposed it at the operation. The 
lower fragment is displaced to the radial side upward and back- 
ward, exactly as it showed at operation. In fractures of this 
type, so oblique that it is difficult to hold the ends in proper 
apposition by splints, one ought to be able to hold them easily 
by doing the extra-articular, non-bloody nailing; but I have 
never had such a case. The plan of the extra-articular nailing 
is to cut a small nick in the skin with a tenotome, put in the 
nail-drill and drill a hole, and then drive the nail through 
exactly as I have done here, or, better, use our new nail-drill. 
The nail-drill is detached from the handle, cut off at the bone 
level, and permitted to remain in. One does not have to 
compound the fracture in this operation. I have never seen a 
fresh case of Colles' fracture which needed nailing to retain it in 
proper position, but it is on this basis that we treat all our elbow 
fractures. 




:? a 



739 




Fig. 237. — Ancient CoUes' frac- 
ture — ununited. Before operation. 
Lateral view, showing the usual ''sil- 
ver-fork" deformity. 



Fig. 238. — Ancient Colles' fracture — ununited. Be- 
fore operation. Anteroposterior view, showing external 
displacement of the hand and the distal fragment. 





i 



Fig. 239. — Ancient Colles' fracture. After 
extra-articular bloodless nailing of the fragments. 
Anteroposterior view, showing complete reduction 
of the deformity. 



741 



Fig. 240. — Ancient Colles' fracture. 
After extra-articular bloodless nailing of 
the fragments. Lateral view, showing the 
reduction of the silver-fork deformity and 
the straight contour of the back of the 
wrist. 



0Ll5^ UNUNITED COLLES' FRACTURE 743 

[Note. — The wound healed by complete primary union, and 
the patient was allowed to return home April 28, 19 14. The 
x-TSiy showed the fracture to be perfectly reduced, as can be seen 
from the plates which are here reproduced. Passive motion was 
begun at the end of three weeks, and the patient already has a 
very useful wrist (June 25, 19 14). — Ed.] 



LEFT FACIAL NERVE PARALYSIS OF CON- 
GENITAL ORIGIN. — MACROGNATHIA. — 
SPINOFACIAL NERVE ANASTOMOSIS 



fflSTORY 

The patient, a girl aged sixteen, entered the hospital with the 
following history: 

Her mother had one miscarriage, which was her first preg- 
nancy. The first full- term child when bom weighed ii poimds. 
This was a thirty-hour labor, with a head presentation and in- 
strumental delivery. This first child had diarrhea from birth 
imtil death, which occurred at five months of age. There was no 
blood in the stools at any time. 

The present patient was her mother's second and last child. 
The delivery was normal; the head presented and labor lasted 
twenty-four hours. The mother has not been pregnant since 
then. 

The patient walked at the age of two and one-half years. 
She began to talk about the same time. She has always been 
bright and quick to learn. She had measles and chicken-pox 
at eight years of age. 

Her menses began at fourteen, are of the twenty-eight-day 
type, painful, as a rule, on the first day. Menstruation lasts 
usually seven days, two napkins a day. Her menses have been 
irregular only twice. The intermenstrual period sometimes 
runs to five or six weeks, and occasionally she misses a whole 
period. 

Her mother says that from birth the patient has had almost 
no control of her mouth, and both lips have always hung away 
from the teeth. There has consequently always been a slight 
drooling of saliva. There has also been some overflow of tears 
from both eyes, especially from the left. The mother noticed, 

745 



746 CLINICS OF JOHN B. MURPHY 

too, that when the child cried or smiled, the mouth would be 
drawn to the right side, and that the left side of the forehead did 
not wrinkle as the right side did. This condition has existed to 
the present time. 

The mother also states that for the past year and a half or 
two years the patient's head has appeared somewhat larger than 
the average. She never noticed this abnormality before two 
years ago. The child complained between the ages of eight and 
fourteen of severe headaches, ascribed diffusely to the whole of 
the head. These headaches disappeared when menstruation 
began. 

In October, 19 13, while combing her hair, the patient sud- 
denly fell to the floor unconscious. The unconsciousness lasted 
for fully twenty minutes, and she seemed stupid, even to her 
mother, for three hours following. During the twenty minutes 
of unconsciousness her whole body seemed bluish and she had 
stertorous respiration. When she regained consciousness she 
vomited about half a cup of blood. The mother is not certain, 
however, whether it was vomited or coughed up. Three hours 
after this attack she began to menstruate, and this was her first 
menstruation in forty-six days. The following day she seemed 
as well as ever. 

She has attended school since she was seven years of age, has 
an excellent memory, and has done average work in school. 
She has always eaten well and slept soundly, and is never con- 
stipated. She is of a lively disposition. Her vision and hearing 
are reported to be good. 

The movements of the jaw appear normal. Sensation on 
both sides of the face is symmetric and normal. The drooping 
of the lower lip and her inability to move it give her face a very 
unintelligent expression. 

COMMENTS AND OPERATION 

Dr. Murphy (April 23, 1914): This is going to be a very 

difficult case to work on, because she has a local gigantism of her 

lower jaw. Whether or not there is a closure of the stylomastoid 

foramen here, of congenital origin, with total absence of the 



LEFT FACIAL NERVE PARALYSIS 747 

facial nerve, is the question. This is a case of congenital paraly- 
sis of both sides of the face, with an enormous enlargement of the 
skull, somewhat resembling the acromegaly which one finds in 
lesions of the hypophysis developing in adult Hfe. The x-ray 
shows an enlargement of the whole skull, as well as an enormous 
enlargement of the lower jaw. The lower jaw is about four 
times the normal size. We cannot tell just how the nerves in 
such a malformation He. The a;-ray does not help us to determine 
whether or not there is a congenital closure of the stylomastoid 
foramen. She has no evidence of facial motion on the left side 
at all, and has never had any from birth. She probably had the 
enlargement of the base of the skull also at birth. 

[Incision.] 

I am keeping well behind the parotid gland in my dissection. 
There is the capsule of the gland. You can see how much the 
normal anatomic relations are disturbed by this great malformed 
mandible, and how difficult it is to tell just where. this facial nerve 
should lie. There is no faradic response to guide us in such a 
case of complete loss of innervation. The question is whether 
there is a facial nerve here at all, or not. If not, we can make no 
anastomosis, and our operation is useless. There is the trans- 
verse process of the atlas under my finger. I can feel it through 
the soft parts, but it is still at a great depth. This bony land- 
mark is the guide to the spinal accessory; but I have no need to 
find the spinal accessory unless I can first isolate the facial. 

[Dissection continued.] 

I appear now to have penetrated to a great depth, but that 
appearance is deceptive, because here is the styloid process, 
which is enlarged materially, and here is also this greatly en- 
larged mandible at the bottom of the wound. 

That strand of tissue looks suspiciously like the nerve. I 
must dissect it out further to make certain. It may possibly 
be a vessel, but it looks more like a nerve. It does not appear 
to fill or empty on pressure, as a vessel should. I will see if I can 
get a response in the facial muscles by stimulating any of these 
fibers with the faradic current. No response, just as one would 
expect in such a degenerated nerve. I am pretty certain that 



748 CLINICS OF JOHN B. MURPHY 

this is the nerve. It seems larger than one should expect it to 
be, considering that it has never had any function. There is 
not the same absence of function on the right side, because she 
has a Httle motion in the upper portion of the right facial dis- 
tribution, whereas there is none at all on the left side. 

[Continues the dissection.] 

That is one of the cervical nerves. Here is apparently a 
slightly infected gland from some unknown cause. You see it 
stands out rather prominently. I will try the faradic current 
again. That is the spinal accessory. [The left shoulder jerks 
upward.] That structure which I just showed you looks more 
like the nerve the further I follow it along. There seems to be 
where it breaks up into its branches — that is all right — that is 
evidently the nerve. [Exposes and divides the spinal accessory 
and apposes the cut ends of the two nerves.] I must not put the 
slightest traction on that suture, because if I do I shall trauma- 
tize the facial stimip. All that is necessary is to rest the facial 
axons in close apposition with the axons of the spinal accessory, 
and the tropism of the axons will take care of the rest of the proc- 
ess of repair. I must keep all traction off that line of suture. 
We place a small gutta-percha drain in the lower angle of the 
wound, because there is parotid secretion in the wound as the 
result of the unavoidable slight injury to the gland incident to 
our dissection. The parotid secretion sometimes disturbs repair 
because of its slight tryptic power rather than the presence in it 
of any bacteria. That is why I am putting in the drain from 
below, and why I shall keep it in situ for seventy-two hours. 

[Usual closure and copious dressing.] 

Let the record show that an incision was made back of the 
left mandible, and the facial nerve exposed slowly and carefully 
because of the great depth at which it lay in this patient; that 
the spinal accessory nerve was then exposed and freed; that 
both nerves were severed, and the distal end of the facial nerve 
was sutured to the proximal end of the spinal accessory with a 
double row of finest silk sutures. 

Regarding nerve suture, we have had, I should say, very good 
results. We feel well pleased with the outcome of our nerve 



LEFT FACIAL NERVE PARALYSIS 749 

suture work. We have been at it rather actively for about 
eighteen years now, and feel that we have a basis on which to 
express an opinion. In these facial anastomosis cases our re- 
sults, with one exception, have been very satisfactory. The 
peripheral nerve sutures have also given good results, with the 
exception of one case iq which we made a homo-transplant of a 
nerve- trunk. A patient died in the hospital during the early 
morning hours of the day of the operation from a trauma. We 
excised, with scrupulous asepsis, the lower portion of his internal 
popliteal nerve, and used it to reestablish a lost connection in 
the brachial plexus of another patient. That procedure did not 
give us a satisfactory result at all, and it is the one imfavorable 
exception. 

Of complete suture of the brachial plexus we have had two 
cases, and they were bad ones, the result of very severe and ex- 
tensive injury. Both were gunshot wounds and both patients 
were shot from behiad. Both the patients were sitting down 
when shot, and the man who did the shooting shot downward 
from behind his victims. The bullet in each case cut right across 
the brachial plexus at the point of formation of the plexus. We 
exposed the trunks thoroughly by dividing the clavicle and throw- 
ing it in an osteoplastic flap out of the field, so that we had 
an unobstructed opportunity to make an accurate dissection. 
Then we made as accurate an apposition as we could of the torn 
nerve-trunks. In these larger nerves we use catgut and not the 
silk which you saw us use this morning. One of these patients 
in seventeen months was back at his work, in spite of the wound 
in his plexus. His work was that of a trunk porter in a hotel. 
He could Hft these heavy trunks and throw them on the wagon 
in a thoroughly efficient way. The other patient was an Aus- 
trian, and was operated on December 22, 1910. To show his 
appreciation of the service we rendered him, on the day preceding 
Christmas, 191 2, he came up here to the clinic, 280 miles, just 
to kiss my hand, as he expressed it. We have pictures of that 
man showing that he can lift me with the hand of his operated 
arm, so complete is the restoration of his function. 

In regard to the case we operated this morning, the question 
which puzzled me most was, how much development would there 



750 CLINICS OF JOHN B. MURPHY 

be of the facial nerve if the styloid foramen were congenitally 
closed by the same process which produced this cranial lesion 
and this giant jaw. This protruding jaw looks like that of an 
acromegalic, notwithstanding that this girl is only sixteen years 
old. I had a rare case in my early nerve experience — an Erb's 
paralysis. The lesion occurred at birth, and I saw the patient 
twenty-six years later. The trunks of the brachial plexus, 
notwithstanding the complete paralysis of the patient's arm, 
were all of apparently normal size. There was a neuroma where 
the division had occurred, but the distal portion of the nerves 
was also of the normal size, which shows that we may accept 
Kennedy's belief as quite correct that an embryonal neuronal 
development may take place in the distal segments after division, 
but that function cannot be restored imtil there is contact of the 
distal with the proximal axonal portion. 

We have said that the neuron theory is the best theory for 
the surgeon. It may not be the best theory for the neurologist, 
but it is the most practical theory for the surgeon. It has worked 
out very well in our surgical cases. 

To secure imion after the division of the nerve we foimd, in 
analyzing the cases, that the most important thing in the surgical 
treatment is to make a sufficient resection of the bulb ends to 
get well back to healthy nerve tissue, just as in resecting necrotic 
intestine in a strangulated hernia it is necessary to cut away the 
bowel well back from the point of strangulation. Where there 
is an end-bulb or a neuroma on the end of the divided nerves, 
we should resect far enough back to see the neural fasciculi 
clearly and distinctly. They resemble bristles sticking out of 
the cut end of the nerve. Then bring the cut ends in apposition. 
As a rule, we endeavor to wrap the point of union in something 
to protect it and to guide the growing axons. This morning the 
cut ends rested in such easy apposition that I thought it unneces- 
sary to wrap the line of union as usual. We usually cover the 
line of union with muscle or fascia and fat. 

[Note, — ^The patient made an uneventful recovery; the wound 
healed by complete primary union. The stitches were removed 
on the twelfth day, and the patient was permitted to go home. — 
Ed.] 



PARALYSIS OF THE RIGHT FACIAL NERVE 
THE RESULT OF A BASAL SKULL FRAC- 
TURE.— FRACTURE OF THE STYLOID 
PROCESS.— SPINOFACIAL NERVE ANAS- 
TOMOSIS 



HISTORY 

The patient, a youth of nineteen, entered the hospital with 
the following history : 

On August i8, 1913, the patient's team ran away and he was 
thrown from the seat down between the horses. He caught the 
tongue of the wagon to save himself. His head and shoulders 
were dragged on the rough ground for a distance of three or four 
rods. He did not lose consciousness at any time. He was 
brought home and put to bed. The doctor who examined him 
found that the left parietal region of the head was bruised and the 
scalp swollen. There was also a bruise behind the mandible on 
the right side, which extended to a point one inch posterior to the 
mastoid. His nose bled profusely from the time of the accident 
until twelve hours later, and then, during the following three 
days, a clear serum discharged through the nose. 

The day after the accident there was present a swelling over 
the right mastoid to the angle of the mandible and down the neck 
to the right shoulder. This swelling was very tender, but sub- 
sided in about ten days. The patient says that at the time of the 
accident his head was forced down violently on his right shoulder, 
and, consequently, for a period of two weeks he had a great deal 
of pain in the left side of the neck, perhaps due to this forcible 
overstretching of the nerves and muscles in the left side of the 
neck. 

Immediately after the accident the right side of the face was 
paralyzed; the mouth was drawn to the left side when the patient 

751 



752 CLINICS OF JOHN B. MURPHY 

laughed or talked, and there was an overflow of tears from the 
right eye which subsided in two months. Now the right eye 
usually feels dry and often bums. Two weeks following the 
injur}' he noticed that the right eye turned inward. This internal 
strabismus continued for two months, when, without treatment, 
the eye again assumed its normal position. He says he has not 
been able to hear anything with the right ear since the time of 
the injury. 

The patient states that for twelve hours after the accident he 
was nauseated and vomited. He had severe headache for forty- 
eight hours. He was kept in bed for four weeks. He has had 
no vomiting without nausea, no "fits" or seizures of unconscious- 
ness, no tingling or numbness in the arms or legs, no loss of sensa- 
tion in the face, no disturbances of speech, no headaches or ver- 
tigo except immediately after the injury. 

COMMENTS AND OPERATION 

Dr. Murphy (April 27, 19 14): That is a very good history, 
as it covers almost all the salient points in connection with the 
case: 

First, he had a trauma. 

Second, following the trauma, or at the time of the trauma, 
he suffered a severe injury to the right side of his head. 

Third, he had hemorrhage from his ear. 

Fourth, he had hemorrhage from his nose. 

Fifth, he had a clear serous discharge from his nose for several 
days after the accident. 

Sixth, he had an immediate and complete paralysis of the 
right half of his face. 

Seventh, he had complete and permanent deafness in his 
right ear. 

Eighth, he had severe vertigo, nausea and vomiting, although 
he was put to bed at once after the injury. 

Ninth, two weeks after the injury he developed an injury of 
the right external rectus muscle and internal strabismus. 

All these signs show that he had not only a fracture of his 
temporal bone, but also a fracture of his sphenoid; and that the 



PARALYSIS OF THE RIGHT FACIAL NERVE 753 

fracture through his sphenoid included a laceration of the dura 
mater, because cerebrospinal fluid flowed from his nose for at 
least three days after the accident. 

From the fracture through the temporal bone he suffered 
what? He suffered a division of his facial nerve as it passed 
through the Fallopian canal, and he also had a division of his 
auditory and vestibular nerves. It was not a pressure paralysis 
of the facial nerve. Why? Because if it were, the paralysis 
would have come on a little later instead of at once. It was an 
immediate and instantaneous paralysis of the facial nerve. It 
was an immediate and instantaneous paralysis of the auditory 
nerve. The auditory nerve is a nerve of special sense. Once 
that is cut or divided it never regenerates, because there is no 
neurilemma on its axons, and all axons without the sheath of 
Schwann are incapable of regeneration. Remember that all 
the nerves of special sense have their cell-bodies in the organ of 
special sense and are incapable of restoration — as the optic, for 
instance. The cell-bodies of the optic nerve He in the ganglion- 
ceU layer of the retina. If you divide the optic nerve back of 
the eye, the loss of function is permanent, no matter how quickly 
or carefully you may suture the nerve, because its axons have no 
neurilemma sheath and are, therefore, incapable of regeneration. 
The same statement holds true for all the other nerves of special 
sense. 

This patient, fortunately, following the compound fracture 
of the sphenoid communicating with his nares, had no infection, 
which was his good fortune, and not due to anything which he or 
his doctor was able to do to prevent it. 

How do we know he had a fracture through his right temporal 
bone? Because he had bleeding from his external ear as well as 
immediate paralysis of his facial and auditory nerves. In these 
cases you commonly have an infection, because the fracture is 
compound. When you have blood escaping from the external 
ear after a severe injury to the skull, that means usually that you 
have present a compound fracture of the temporal bone with a 
laceration of the meninges; and there may, consequently, be 
an escape of cerebrospinal fluid as well as of blood. That is why, 
VOL. m— 48 



754 CLINICS or JOHN B. MURPHY 

when you see blood coming from the external ear after cranial 
trauma, you should paint the outside of the ear thoroughly with 
iodin, pack the ear with sterile gauze packing, and apply sterile 
dressings just as carefully as you would to any other compound 
fracture. That is the matter of first importance in the manage- 
ment of these cases. Do not irrigate the ear, but dress it dry. 
Put on enough material to soak up the escaping fluid, and renew 
the dressings as often as they become saturated. If you are 
expert at examining an ear and wish to make a more accurate 
prognosis for an unconscious patient, you may wipe out the ear 
carefully with sterile cotton on an applicator and locate the 
bleeding. If the bleeding point is in the external meatus, the 
prognosis, as to both life and hearing, is better, naturally, than 
if the bleeding comes from a ruptured drum-membrane, because 
fractures which involve the middle ear are much more likely to 
involve the cochlea and labyrinth or the auditory nerve, which it 
must have done in this case, and also much more likely to open 
the meninges than are those fractures involving only the external 
auditory canal. 

The next question which comes up is: Has he an obstruction 
in the course of his facial nerve which interferes with the restora- 
tion of the nerve? Even if we knew he has such an obstruction, 
it is practically useless for us to try to reach it in the temporal 
bone and remove it. Restoration of the auditory nerve is im- 
possible, however, not merely because it is impossible to reach it, 
but also because it is a nerve of special sense and, therefore, 
incapable of regeneration. Lesions of the nerves of special sense 
follow the same rule as lesions of the spinal cord above the cauda. 
Whenever the spinal cord is cut at a level above the cauda, the 
division is in a zone where the axons have no neurilemma, and, 
therefore, there can be no regeneration. In order to understand 
regeneration in the nervous system, one has to bear in mind 
only a few things: 

First, the neuron theory, and that is the practical theory for 
the surgeon. 

A neuron is made up of its cell-body with its nucleus and the 
elongations of that cell-body which are the axis-cylinders and 



PARALYSIS OF THE RIGHT FACIAL NERVE 755 

the dendrites. The axis-cylinders are surrounded in some of the 
nerves by two additional coats, the myelin sheath and the 
neurilemma. 

The myelin or medullary sheath has practically nothing to do 
with regeneration. The regenerative sheath is the neurilemma. 
Therefore, whenever you have a nerve divided, the first question 
you ask is, what sheaths have its axons? The axis-cylinder, or 
axon, which is a prolongation of the protoplasm of the cell-body, 
has always, except in the sympathetic system, a myelin sheath. 
It has everywhere, except in the nerves of special sense, in the 
brain and in the spinal cord above the cauda, a neurilemma; and 
the presence of a neurilemma is absolutely necessary for the 
regeneration of an axon. Whenever you have a nerve cut, you 
ask, ' ' Has it a neurilemma? " If it has a neurilemma, it is capable 
of regeneration if you properly adjust it. If it has no neuri- 
lemma, it is incapable of regeneration, no matter how soon or how 
well you adjust it. For instance, if you divide the spinal cord 
high above the cauda, no matter whether you suture it in five 
minutes or in five years, it is incapable of regeneration. Micro- 
scopically, its axons may sometimes be seen to have made abortive 
attempts at regeneration; but those end-bulbs seen here are never 
able to penetrate successfully the scar tissue formed in the cord 
at the site of injury. Only where a neurilemma is present are 
axons able to penetrate such a zone of division. If you divide a 
peripheral nerve, however, it will regenerate if properly adjusted. 

We have here a paralysis of the facial nerve, probably from 
division; but whether from division or compression does not 
matter now. The point of importance at present is that we can 
no longer expect regeneration to occur. 

Two weeks after the injury the patient developed a paralysis 
of the right abducens, but the function of the abducens has now 
returned spontaneously. We frequently get a somewhat similar 
paralysis of the abducens in operating on the Gasserian ganglion; 
but all these paralyses which we have seen have eventually dis- 
appeared except one case, which we have in the hospital now; 
but it is really still too soon after his operation for a return of 
motion to have occurred. 



756 CLINICS OF JOHN B. MURPHY 

What can we do now to restore function to this divided facial 
nerve? Here we cannot overcome the obstruction which blocks 
the nerve in the petrous portion of the bone where the fracture 
was, but we can run motor impulses from the brain out through 
another motor nerve-trunk and connect the facial nerve with 
this other nerve-trunk, and thus make it functionate. In other 
words, we can transplant the peripheral end of the spinal acces- 
sory or of one of the other motor nerves — that of the tongue, the 
h>poglossal — into the facial nerve, which will then receive all 
its motor impulses from the cerebral cortex through the hypo- 
glossal or spinal accessory. Thus he will regain the power of 
expression in his face and the ability to use his facial muscles as 
soon as he trains himself in the use of his new motor pathway. 

I think this is not going to be so difficult a case as the one we 
had last week. The other was difficult from an anatomic stand- 
point because she had a gigantic lower jaw, which made the nerve 
lie much deeper than in the average person. Her's was a con- 
genital absence of function in the facial nerve. We feared, on 
account of the skull changes present, that she might have com- 
plete obliteration of the stylomastoid foramen, through which the 
facial nerve comes out, and, therefore, entire absence of the facial 
nerve; but, fortunately, this proved not to be the case. 

[Incision.] 

There is the parotid, you see, shining right here. We must 
go behind it, and that necessitates dissecting well backward. 
[Shows illustration from his article on Nerve Regeneration in 
Surgery, Gynecology, and Obstetrics, 1906.] 

There is a picture I had made for the original article which I 
wrote on this subject some years ago. That gives you, probably, 
a better idea of the steps of this operation than you can get from 
most text-book pictures, because it was made especially for this 
article. 

Now I am dissecting it from behind and trying to come upon 
and expose that nerve while keeping entirely in front of my field 
of operation. Now we are coming to the mastoid process. The 
excitor has little or no value here in locating the nerve, since all 
the nerve-fibers have, probably, long ago imdergone degeneration, 



PARALYSIS or THE RIGHT FACIAL NERVE 757 

and are, therefore, now incapable of transmitting faradic im- 
pulses. There is the parotid gland, you see. The nerve should be 
Ijong now very close to the apex of our present field of operation. 

[Continues the dissection.] 

This case is not working out as nicely as I thought it would, 
nor as nicely as did the case of the other day. There is the 
styloid process. It appears to be fractured at its base, and its 
tip is bent backward and rests against the mastoid process, to 
which it appears closely adherent — in fact, there seems to be bony 
union present between the two. Let me see if that is correct. 
If it is, then it may be inside this bony mass that the nerve lies. 
There, you see, the styloid process now is easily brought into 
view for all its length. Let us see if we cannot find the nerve 
displaced below that tip. In the presence of such a complica- 
tion I should rather expect the nerve to come out beneath the 
point at which bony fusion has occurred. There, apparently, 
is where the nerve should be embedded. I must first remove 
this styloid process, and then I shall search below its present 
site and see if I can find the nerve. There is a little vessel here 
which might be annoying, so I shall ligate it. Now I should be 
able to pick up some fibers of the nerve. Here are some, ap- 
parently, but not enough to justify me in dividing the spinal 
accessory and bringing it up to them. If I cannot do better 
than that, I shall do nothing. We ought to be able to find some 
more filaments of it. If there are not enough facial fibers present 
to make a good union, I feel that we are not justified in sacrificing 
the other nerve with so slender a prospect of a successful anas- 
tomosis. These fibers run into the parotid gland, but seem to 
have been disturbed in their relationship to it by this bony 
anomaly. They lie way down and almost out of the field. 
Perhaps we shall be able to locate the nerve lower down, so I shall 
dissect more posteriorly to see if I can find anything there re- 
sembling a nerve- trunk. I am very reluctant to give up this 
search, because it means a permanent facial paralysis for this 
boy if I do 

There! that looks like the nerve. I have finally found it. 
[Dissects it free and exposes it for some distance.] There it is 
all right. That was a hard one to find. You can all see it now. 



758 CLINICS OF JOHN B. MURPHY 

Its axons are evidently all divided, because they do not respond 
to the faradic current. The nerve is far out of its usual position, 
owing to the fracture of the styloid. 

I shall use the spinal accessory to make the anastomosis. 
The spinal accessory should come right across the field here on a 
line between the easily palpable transverse process of the atlas 
and the anterior border of the stemomastoid. There it is. We 
have now identified it by following it clear back to the trapezius. 

Now you get a nice view of the whole situation. I have 
divided the spinal accessory and the facial and have anastomosed 
the two nerves end to end with fine catgut. I think that the single 
strand of phosphor-bronze wire or silver wire would serve just 
as well as, or better than, iodin catgut because these metals 
cause no irritation. I always feel when I start one of these opera- 
tions that I should like to do as did Christian Fenger, when per- 
forming the radical removal of the glands of the neck. He would 
take a bath, eat his lunch, put on rubber trousers and apron, 
prepared to stay all day; then the dear Dane would start to 
work, and what he could not do when he had plenty of time was 
scarcely worth mentioning. 

There is a tropism or attraction of these motor axons to one 
another which was brought out many years ago by Thoma, 
particularly in connection with the nerves of respiration. 

There must be no tension on the nerves or on the line of suture 
if one wishes to get a successful union. I have taken a long piece 
of the spinal accessory nerve to form the anastomosis in order 
to be certain to avoid tension on the sutures. There can be no 
contraction of the sternocleidomastoid now because its nerve 
supply is divided. We embed this line of union within the belly 
of the stemomastoid muscle in order to protect it from wound 
reaction and lessen the amount of connective-tissue formation. 

Let the record show that there was a fracture of the styloid 
process, dating back, in all probability, to the time of the original 
accident; that it was displaced downward, and its edge and tip 
were adherent to the mastoid; that the deformity caused by this 
fracture made it difficult to locate the nerve; but that finally we 
located it; that the spinal accessory was then brought into the 
field, divided, and the two nerves accurately apposed with two 



PARALYSIS OF THE RIGHT FACIAL NERVE 759 

catgut sutures; that a small gutta-percha drain was inserted 
at the lower angle of the wound. 

In performing this operation one should keep close to the 
anterior border of the sternocleidomastoid and close to the mas- 
toid process. Dissect and divide all the vessels and cervical 
nerve filaments which pass forward until you come to the under 
surface of the upper angle of the parotid. Then the tissues should 
be spread and freed with the dissecting scissors, the spreading 
being done parallel to the zygomatic line. 

The drain will be removed in seventy-two hours. Its purpose 
is to carry off such salivary secretion as may trickle into the 
wound from the exposed parotid. That is why it is left in so 
long. We should get a good result here if Dame Fortune treats 
us at all fairly. The patient will have some associated move- 
ments for a time when he first uses his facial muscles, but after 
a while they will subside. 

[Note. — The wound healed by complete primary imion. The 
stitches were removed and the patient was allowed to leave the 
hospital May 5, 1914. — Ed.] 

[Note. — The following letter, received recently by Dr. Murphy, 
shows what excellent functional results may be obtained in these 
cases of complete facial nerve paralysis of organic origin by means 
of implantation of the facial into the spinal accessory nerve. 
This patient, a woman, had the spinal accessory anastomosis 
done in June, 1906, and the case was reported in Dr. Murphy's 
article on neurologic surgery in Surgery j Gynecology, and Obstetrics 
for that year. — Ed. 

Wellsburg, W. Va., July 8, 1914. 
Dr. J. B. Murphy, 
Chicago, 111. 

Dear Doctor: In answer to your inquiry of the 7th ult., I 
must confess that I have not seen the patient since last winter, 
as she is now living somewhere in Ohio. At that time her face 
was in good condition — the muscles were imder good nerve con- 
trol, there was no drooping at the angle of the mouth — ^in fact, 
I regard the anastomosis and result as nine-tenths perfect. 

Very truly yours, 

Dr. John B. Walkinshaw.] 



INTRA-UTERINE FIBROID.— HYSTERECTOMY 



HISTORY 

The patient, a married woman aged forty-five, entered the 
hospital March 31, 19 14. 

Her family history is negative for tuberculosis and cancer. 
She has had two miscarriages. Her menstrual periods began at 
twelve years of age, occur regularly every twenty-eight days, 
and are from three to four days in duration, two or three napkins 
a day being used. She used to have severe continuous pains all 
through her periods until January, 1913. About January 20, 
1 913, she began to menstruate two days before her period was 
due. The flow lasted one day and then ceased entirely. She 
had no pain at this time. One week later, on Sunday, while 
sitting in a chair, she suddenly expelled a large clot of blood 
without any premonitory symptoms or signs. This clot was 
followed by a severe hemorrhage. From this time on she con- 
tinued to flow all through the remainder of the month, also 
through February and up to about March 20, 1913. Some days 
she would use one or two napkins, and on other days 10 or 20. 
There was no odor to the discharge. During February she 
called a doctor, who gave her ergot and said she might be preg- 
nant or she might have a fibroid. The ergot did no good. In 
April and May she flowed every twenty-eight days, from four to 
five days in duration, and from five to six napkins daily, with no 
odor. About June 20, 19 13, she began again to menstruate at 
about the regular time, and continued to flow until November, 
1913, using from 6 to 20 napkins daily. She frequently passed 
clots, but had no pain. In November the flow continued for 
two weeks and then ceased for two weeks. Then she flowed for 
two weeks more. This perpetual flow has continued up to the 
present time (March, 19 14), blood coming away continuaUy all 

761 



762 CLINICS OF JOHN B. MURPHY 

through this month. She has never had pain. She has not 
noticed a tumor in the abdomen, but at times the abdomen is 
distended, she thinks. The bowels are constipated, her appetite 
is good, and she has lost little weight; but she feels weak con- 
tinually. 

COMMENTS AND OPERATION 

Dr. Murphy (April i, 19 14): How was the menstruation 
before January, 1913? 

Intern: It was perfectly normal up to January, 19 13. 

Dr. Murphy : What do you mean by normal? 

Intern: Regular, twenty-eight-day type, from three to four 
days' duration, from two to three napkins a day. 

Dr. Murphy: That is not enough. Was it more in January 
than in December, 191 2? Was it more in December, 191 2, than 
in December, 191 1? 

Intern: No change since the time she was twelve. 

Dr. Murphy: If that statement is true, the diagnosis of 
uterine fibroid is wrong. Either the statement is wrong or the 
diagnosis is wrong. Why? Because her illness began with a 
sudden hemorrhage, according to the doctor's story — a sudden 
hemorrhage without a history of pregnancy and without any 
intermission of or elongation of her periods beyond her normal 
time, her normal interim. Her illness began with the passing 
of a large clot. She does not know whether it was a miscarriage. 
The doctor describes the clot as having been expelled without 
pain. With a fibroid she should gradually develop her signs and 
symptoms, unless she had a pregnancy and the contents of the 
uterus were expelled, or unless she had some other disease of the 
fundus, such as a carcinoma of the fundus and not a fibroid. 
This history is not correct. The first part of the history does not 
fit the diagnosis. Read the rest of the history and let us find 
out more about the case. 

[Intern reads.] 

Dr. Murphy: The history, you note, along from that time, 
is that of a fibroid. The history in the beginning is not that of 
an uncomplicated fibroid, but suggests the presence of a preg- 



INTRA-UTERINE FIBROID. — HYSTERECTOMY 763 

nancy or some other lesion. If it were a fibroid, she should have 
a gradual increase in the quantity of the flow up to the time when 
she showed the more profuse flow. You see she has here all the 
appearances of a fibroid. There was no infiltration of the cervix 
found on vaginal examination. 

[Usual mediolateral abdominal incision.] 

The operative method we use has been our technic for a great 
many years. We have foimd it very satisfactory. It was pub- 
lished by Dr. Neff, my former associate, at one time in the Illinois 
State Medical Journal and buried there. 

[Brings up uterus and begins to amputate it from behind.] 

The incision in the uterus is made at the cervicocorporeal junc- 
tion. I am freeing the uterus a little so as to bring it out further 
and get it ready for the additional clamp, which the doctor will 
put on to prevent the return bleeding. Now we shall divide this 
loose tissue down to the cervicocorporeal portion of the uterus. 
This fibroid, on account of the profuse bleeding it has caused, 
lies, probably, close to the mucosa. One clamp now goes on the 
broad ligament down to the cervix and then the broad ligament 
is divided between the two clamps. We next commence the 
removal of the uterus. We go fairly high up on the peritoneum 
in our amputation, so as to have a stronger portion of the uterus 
to catch subsequently. We amputate here from behind forward. 
We shall soon come to the cervix. There is the cervical canal 
now open. We touch this canal with a little tincture of iodin. 
Now we pass this volsellum forceps around the cervix and catch 
the cervical canal and thus close it. We are rolling the fundus 
forward. Now we shall look for the uterine arteries. Here 
they are. We put the volsellum on the cervix to hold it in con- 
trol during the remainder of the work. Thus we are always 
masters of the situation. You will note that in cutting down on 
this cervix we came on it in the regular way, and we knew all th® 
time just where the uterine arteries lay. Then we found the 
ureters. Remember, the ureter lies always just to the outer side 
of the uterine artery. 

Visiting Doctor: Do you catch the uterine artery with this 
clamp [the angiotribe] ? 



764 CLINICS OF JOHN B. MURPHY 

Dr. Murphy: Sometimes I do and sometimes not. I en- 
deavor not to catch it. One can always tell whether he has it or 
not when he takes off the clamp. When you do catch or expose 
it, then put on a separate ligature, just as you would on the radial. 
Tie it separately and not with a mass of material. 

We are now suturing the angle of the muscularis of the cervix. 
Now we sew over all of that muscular surface. This present 
portion of the procedure is very old. It was being done by Bill- 
roth when I was in Vienna in 1882, and has been followed out in 
practically the same way ever since. In covering the muscularis 
of the cervix we are making the flaps overlap and are including 
only the muscularis in the suture. 

Remember that in the history the doctor said there was no 
odor from that discharge. He meant to infer from that state- 
ment that there was no cancer of the uterus or cervix here. 
That point has only a relative value, however, in making the 
differential diagnosis. Remember, the odor is not due to the 
cancer itself, but comes from the saprophytic infection of the 
cancer. There is no intrinsic odor to a cancer. There is a 
clinical odor to uterine cancer often after the patient has once 
been examined or manipulated by a doctor; but it is the com- 
munication of the saprophytes to the cancer which gives the odor. 

We have sewed both of these edges. The muscularis of the 
cervicocorporeal portion is cared for. We must cut off the broad 
ligaments. You see they are clamped here. See! we catch the 
peritoneum at this side. That should bleed under ordinary 
circumstances at only two points. Here it does not bleed at all. 
That is on account of this woman's blood-pressure being so low. 
Now it is coming. It bleeds at two points and you ligate these 
two points separately. That is in the crease which was made by 
that clamp. These are both cared for. Put in the final closure 
and fix the bleeding points down to the neighborhood of the 
cervix, and you have all that ligating done in the place where you 
had your angiotribe, where you have the best possible compres- 
sion of the blood-vessels themselves, and you have no extraneous 
tissue. Top-sew the wound with the same needle and cover it 
over to the stump of the cervix. Turn it in to secure it and then 




Fig. 241. — Large subserous fibromyoma of the uterus removed by the abdominal 

route. 



765 



INTRA-UTERINE FIBROID. — HYSTERECTOMY 767 

top-sew it. Here are the uterine artery ligatures which I have 
kept in view all the time. Now we will turn over and pick up 
the other comer of the cervix and the other broad Hgament and 
treat them in like manner. 

We have accomplished the removal of that uterus, and all the 
time we were absolutely masters of the situation so far as the 
ureters were concerned, and so far as the uterine arteries were 
concerned. Do you notice there are no raw surfaces left? Here 
is the sigmoid, the doctor's friend, or, rather, the gynecologist's 
friend. I shall just let the sigmoid fall over the line of sutures. 
In closing the peritoneum I am making an ectropion of the cut 
surfaces, so there will be no abraded areas left within the perito- 
neiun. 

[Examines the specimen.] 

Here is a general enlargement of this uterus. [Cuts it open.] 
There is the fibroid, which has become necrotic within the uterine 
cavity, which probably accoimts for the sudden onset of the symp- 
toms. Strangulation of the fibroid within the uterine cavity 
fits this history well. That explains why the woman had the 
sudden onset with hemorrhage. This fibroid has been extruded 
out of the uterine musculature into the uterine cavity. 

[The wound healed by complete primary union. The patient 
left the hospital April 25, 1914, entirely relieved of her previous 
symptoms. — Ed .] 



FACET'S CANCER 



HISTORY 

The patient, a married woman aged forty, entered the hos- 
pital May 21, 1 9 14, with the following history: Her family his- 
tory is negative for mahgnancy. The patient states that in the 
spring of 191 2, two years ago, she was struck a severe blow on the 
left breast with the handle of a wringer. Four or five days later 
she noticed a small tumor, the size of a bean, at the site of the 
injury. The tumor grew gradually to its present size. 

About a year and a half ago she noticed on the left side of the 
nipple a small sore, the size of the head of a pin, which was not 
painful or tender. This sore has gradually increased in size. 
Last summer she noticed that her clothing often stuck to the 
nipple, and, when it was removed, the nipple bled. Since then 
she has had constantly to wear a cloth over the nipple on account 
of the serum which discharges. She says that the sore involves 
the entire nipple now. She has neglected to see a doctor until 
now for fear he might call the tumor a cancer! 

COMMENTS AND OPERATION 
Dr. Murphy (May 25, 19 14): There is just one deviation in 
that story from the ordinary case of Paget's cancer, and that is a 
very interesting deviation, for it accentuates again the pathology 
of "Paget's disease." She had what? A trauma. The trauma 
was not of the nipple, but away from the nipple. Shortly after 
the traiuna she began to have a slight discharge of yellowish, 
milky-colored material from the nipple. That means what? 
That means that the cancer secretion coming out of the milk- 
ducts produced the irritation on the surface of the nipple, which 
is characteristic of a Paget's cancer. Remember, Paget's cancer 
is not primarily a cancer of the skin of the nipple. It is a cancer 
VOL. in — 49 769 



yyo CLINICS OF JOHN B. MURPHY 

of the milk-duct. The first sign of a Paget's cancer is a little 
yellow secretion from the nipple, and that little yellow secretion 
keeps coming and coming; it irritates and finally destroys the 
squamous epithelial cells of the nipple and produces an ulcer. 
All this happens before you see the cancer. Is that clear? 

A patient with Paget's cancer is much like the boy who has 
pushed a bean up his nose. He usually will not admit what he 
did until his upper lip becomes swollen and ulcerated from the 
nasal discharge produced by the irritation of the bean. 

The pathogenesis of Paget's disease is exactly the same. It is 
the discharge coming by way of the milk-ducts from the malig- 
nant disease within the breast which first irritates the nipple. 
Then there is produced the inflanunation of the skin which is 
called ** eczema"; next the inflammation results in ulceration, 
which is usually more or less superficial. Sooner or later the 
underlying cancer becomes manifest, and the lesion is finally 
called a cancer, when, in reality, the cancer was at the back of it 
from the very beginning. That is a very important fact, which 
cannot be too much emphasized. When you figure out that a 
case of Paget's disease with only that little perimammillary 
irritation as its manifestation has ultimately over a 90 per cent, 
cancer mortality, even when submitted to the radical operation, 
the thought is appalling. Why so great a mortality? Because 
the patients wait after that little irritation appears and postpone 
the inevitable operation. They treat the nipple with salves, 
pastes, and Denver mud; they try about everything of that kind 
on it, and yet from the very first day it was seen it was a cancer; 
from the first moment that little discharge appeared the lesion 
was mahgnant, and this type of cancer is so terribly malignant 
that, even if operated when first noticed, it would probably give 
only about 10 per cent, of cures. In addition to its intense 
natural malignancy it is not treated as a cancer should be treated. 
It is treated, usually, as an eczema or as a simple ulcer — in a 
purely palliative way. P-a-g-e-t-s disease always spells cancer ^ 
and should he called Paget's cancer. 

Look at it! Here is a beautiful picture of the rather more 
advanced stage. A point I want to call your attention to is 




Fig. 242. — Paget's Cancer of the Breast. 
Note the red and "weeping" skin surface of the nipple and areola, due to the 
irritating discharge of cancer-juice from the milk-ducts. Note that the skin of the 
areola shows a somewhat wider involvement below and to the outer side of the nipple 
than above and to the inner side, corresponding to the wider distribution of the 
cancer-juice in these directions by the force of gravity. Note the relatively slight 
retraction of the nipple — slight, because Paget's cancer is glandular rather than 
scirrhous in type. Note the prominence of the cutaneous veins, the expression of a 
collateral circulation made necessary by the blocking by the tumor growth of the 
vascular channels inside the breast, and also an indication of a rather vascular tumor, 
as the glandular cancers usually are. Note that local metastasis in the breast has 
already occurred in the outer upper quadrant. This local metastasis is already 
larger than the primary tumor situated beneath the nipple, rather a characteristic 
feature of Paget's cancer, which produces early and rapidly growing metastases, 
while the primary tumor may long remain apparently insignificant. 

771 



facet's cancer 773 

this — ^it is only a few minutes since the raw area about the nipple 
was dressed, and now see the fluid pouring out of the nipple from 
within — a clear serous fluid! That is the secretion from the can- 
cer in the milk-duct within. That is what produced the eczema. 

Paget's disease, as a rule, does not appear as the result of a 
trauma of the nipple. This case, however, is one which began 
after a blow on the breast. The thin, serous secretion then pro- 
duces the irritation and the eczema. According to the history, 
this patient told us at the office that she noticed first the pus 
around the nipple and then the discharge from the nipple. That 
is the wrong order. If she were a more observant patient, she 
would have noticed first the discharge from the nipple and then 
the pus around it; that is the proper order. 

Visiting Doctor: Does that serous discharge ever come from 
anything else? 

Dr. Murphy: No. You may have a milky discharge in 
some forms of breast cysts, but this discharge does not produce 
perimammillary eczema and does not produce that red area 
which you see at the end of the nipple. This lactiferous discharge 
is the result of stimulation of the glandular acini by the growing 
tumor, or may be the product of proHferating pathologic paren- 
chyma. You will find among the cases reported in the current 
(August) number of the Clinics a cancer of the breast in which 
there was a milky discharge from the nipple preceding the ap- 
pearance of the tumor; finally the discharge ceased, and the 
tumor appeared some Httle time later. There was no irritation 
of the skin until after the tumor had been there for many months. 

This serous discharge here accentuates the deviation from 
the average case of breast cancer beautifully. See that streak 
which the discharge has made on the iodin which we used to 
prepare the breast for operation! It has discolored the iodin, 
bleaching it out. We should have tested the reaction of that 
fluid as it came out of the nipple to see whether it is acid or alka- 
line. It bleached out the iodin merely in the short time which 
elapsed while the patient was being brought in to the amphitheater 
from the anesthetizing room. 

[Dr. Murphy then removed the breast, together with the 



774 



CLINICS OF JOHN B. MURPHY 



pectoralis major and minor aponeuroses and the axillary glands 
and fat. The pectoralis major and minor were detached from 
their costal attachments, and used to pad the axillary cavity. 
The details of Dr. Murphy's radical operation for breast cancer 
are printed and illustrated in the June, 1914, Clinics. — Ed.] 

[Note (July 3, 1914). — The wound healed by complete 
primary union, and the patient left the hospital June 7, 19 14. 
She had no edema of the arm and no pain at any time. — Ed.] 



CARCINOMA OF THE RECTUM WITH ULCER- 
ATION.— ILIAC SIGMOIDOSTOMY.— RADI- 
CAL EXCISION 



HISTORY 



The patient is a married man, forty-five years old. His 
family history is negative regarding maHgnancy. One brother 
died of pulmonary tuberculosis. The patient has been married 
one year, but his wife has not yet become pregnant. At twenty 
years of age the patient had a soft chancre, but showed no second- 
ary signs of syphilis and received no specific treatment. He has 
had gonorrhea, the last infection in 191 2. For two months in 
that year he had frequent prostatic massage. 

For the past six months the patient says he has been losing 
weight, having lost 20 pounds since November, 19 13. In March, 
1 9 14, the patient began to have difficulty in starting urination, 
and he noticed that the stream was smaller than normal. There 
was no burning on urination. He at once consulted a doctor, 
who passed without difficulty a sound (No. 24 French). The 
prostate was examined and found to be very slightly enlarged. 
The patient's condition did not improve, so he consulted another 
doctor, who made a proctoscopic examination and saw an ulcer 
of the rectum which he thought might be malignant. A Wasser- 
mann test, made April 13, 1914, was reported as negative. The 
patient says that very seldom he has had a sharp, stabbing pain 
in the rectum. He has noticed for the past three months, after 
going to stool, a slight amount of blood on the toilet paper. He 
has been stubbornly constipated since February, 1914, although 
he was always regular in his bowel movements before that time. 
He says that he never has passed any mucus, so far as he knows. 
He has never had bloody stools, either black or red. His appe- 

775 



776 CLINICS OF JOHN B. MURPHY 

tite is good. He tires easily. His wife says that since about 
January, 19 14, he is paler than normal. 

Proctoscopic examination by Dr. Murphy shows an ulcerated 
carcinoma lying just above the sphincter and involving the whole 
circumference of the bowel over an area from i^ to two inches 
in width. The sphincter probably cannot be conserved in the 
radical operation because of its close proximity to the tumor 

COMMENTS AND OPERATION 

Dr. Murphy (April 18, 1914): The growth begins iK or 
two inches above the sphincter, and extends upward for about 
the same distance. It is annular in type, involving the entire 
circumference of the bowel. The history of this patient is not 
the typical history of a case of carcinoma of the rectum. In a 
classic history of rectal carcinoma one finds, first, blood in the 
stools; second, the passage of mucus occurring independently 
of the discharge of feces; third, feces mixed with mucus; fourth, 
straining constantly necessary to secure a bowel movement, the 
difficulty of the passages constantly increasing; fifth, finally, 
bowel movements are secured only with the aid of cathartics or 
enemata, and, in some cases the obstruction may become com- 
plete, the last type representing the superlative stage of the 
disease. 

Often these patients come to the doctor complaining of blood 
in the stools. The blood is usually ascribed to hemorrhoids. 
The patients, when examined superficially, are given pills and 
salves and the cancer is permitted to continue its course for a 
considerable period of time, often, before an accurate examina- 
tion is made of the interior of the rectum. Occasionally these 
patients may have profuse hemorrhages lasting for days, but the 
bleeding from a rectal carcinoma differs in character from that 
due to hemorrhoids. The differentiation from carcinoma may be 
particularly difficult in the "slit type" of hemorrhoids, in which 
a tiny linear rupture occurs in one of the internal group of veins. 
It is in the latter cases that you may have a very profuse hemor- 
rhage without an apparent cause visible or palpable in the lower 
rectum, except on very minute examination. We have had two 



CARCINOMA OF THE RECTUM WITH ULCERATION 777 

such cases since the first of January, 19 14, both of which patients 
looked like pernicious anemia cases because of the tremendous 
loss of blood. One of them had his hemoglobin down to 1 2 per 
cent., the lowest reading I have ever seen. He would faint at 
the slightest provocation. The other patient had 30 per cent, 
of hemoglobin for a considerable period of time after the opera- 
tion. This last patient had the s)nnptoms of an anemic tabetic. 
She walked with an unsteady gait and had a positive Romberg 
test. She did not have the Argyll-Robertson pupil, but her deep 
reflexes were entirely absent. It was not a case of tabes plus 
anemia, however, but a combined degeneration of the posterior 
and lateral coliunns of the cord, due to the severe secondary 
anemia. Usually these cord changes are due to a primary per- 
nicious anemia, but occasionally, as in the case just cited, they 
may accompany a severe case of the secondary type. A careful 
study of the clinical aspect and course of the affection, as well as 
the study of the blood picture, will save one from the error of 
diagnosing such a case as one of pernicious anemia, and thereby 
giving a prognosis as gloomy as it is false. 

On examination of the rectum in these cases of fissured hemor- 
rhoids one may find practically nothing at all abnormal there, 
and the apparent absence of local pathology in the lower rectum 
may lead one to suspect pathologic changes higher up, par- 
ticularly cancer. We have had three cases of this type in which 
nothing was discovered on first examination of the rectrnn with 
the proctoscope; yet, when a stool was examined, a mass of 
formed feces would be found resting in a pool of blood, a sign 
which settles positively that the bleeding is from hemorrhoids. 
The hemorrhage from a rectal cancer is more of a serous discharge 
tinged with blood — not often pure blood. 

Nobody knows how long the cancer has been present in this 
patient's rectum. The question comes up, can we retain the 
anal sphincter when we excise this tumor? No, we cannot do 
so, because the growth lies too close to the sphincter. If, then, 
we must excise the sphincter, we must also make an artificial 
anus, and the best location for an artificial anus is in the left 
iliac region. Our operation today will consist in establishing aa 



778 CLINICS OF JOHN B. MURPHY 

artificial anus. We shall wait after this operation until the edema 
and the inflammatory infiltration and infection in and around the 
carcinoma shall have subsided. By that time one can get a 
much better idea as to the extent of the carcinoma than one can 
get when irritation and infection are increased by the feces con- 
stantly passing through the rectiun. After opening the ab- 
domen today I shall also examine the iliac glands to see whether 
they show any sign of containing metastases. 

We are slowly coming to the combined operation for the cases 
of carcinoma of the rectum in the hope of obtaining a larger 
number of permanent cures. I do not believe that the number of 
cures is increasing appreciably. The outlook for ciures does not 
look promising to me, but the operation prolongs life and in- 
creases the comfort of the patient during that prolongation. 

[Incision.] 

We make the incision far enough from the anterior superior 
iliac spine so as not to have the latter interfere with the cup which 
will protect the artificial anus. We are keeping fairly well 
medianward in making the incision. All sorts of methods have 
been suggested and tried in order to gain control of the feces 
with the aid of the muscles of the anterior abdominal wall, but 
all these procedures thus far have been failures. We are entering 
the abdomen at the outer margin of the rectus muscle. 

Another conclusion to which we are coming is that after these 
operations the abdominal anus is preferable to the sacral anus, 
being easier to care for, while it is more comfortable and more 
easily protected. I am palpating along the internal iliac vessels 
and I can feel no enlargement of the glands there or elsewhere. 
I have my index-finger above the promontory on the inner side 
of the left artery and the vein, to serve as a guide to subsequent 
procedures. My intention is to perform sigmoidostomy. We 
intend to divide the bowel ultimately, leaving two separate 
pieces of gut opening on the surface of the abdomen close to- 
gether. Later we shall close the lower end of the rectum entirely 
when we do the second step of the operation — the excision of the 
tumor. Thus we shall keep the fecal flow out of the rectum and 
yet provide free drainage for rectal secretions. [The sigmoid 



CARCINOMA OF THE RECTUM WITH ULCERATION 779 

is brought out on the abdominal wall, an opening is made in its 
mesentery, and parietal peritoneum and rectus aponeurosis are 
imited through this opening in the mesentery, thus holding the 
loop of sigmoid firmly in position outside the abdomen. Parietal 
is united to visceral peritoneum, and the abdominal wound is 
closed about the extruded sigmoid.] We shall not open the bowel 
for from forty-eight to seventy-two hours, depending upon the 
patient's symptoms. If he has symptoms of fecal retention, 
then we may have to open the loop earher. If he does not have 
such difficulty, then we need not open it until complete agglutina- 
tion of the peritoneal surfaces has occurred. We are leaving an 
opening ample for the bowel movements. 

The prognosis in any form of cancer depends primarily on 
the prognosis of the operation for its removal. The combined 
operation for the removal of cancer of the rectum has a mortality 
of from 25 to 28 per cent. The number of immediate mortali- 
ties is greater than the number of permanent recoveries, a per- 
centage relationship which to us seems discouraging. The reason, 
I beHeve, that the mortahty is so high is that these cases come to 
us for operation so late. We say "late," although we really do 
not know exactly what late is, either in cancer of the rectum or 
in cancer in most of its other locations in the body. ''Late" 
in cancer of the rectum is always a relative matter, without 
exactness. Recurrence in cancer of the rectum after operation 
depends very materially on the location of the cancer, as well as 
on its duration before operation. If a carcinoma is situated in 
the first portion of the rectum, where the fold of peritoneum 
passes from the rectum to the bladder, early recurrence is the 
rule, because there is a very rich lymphatic supply at that point. 
If the carcinoma occurs in the middle portion of the sigmoid, 
where there is a very sparse lymphatic supply, it offers a very 
much better opportunity for a permanent cure. When the car- 
cinoma occurs low down in the rectum, just at or just inside the 
sphincter ani, where there is a rich lymphatic supply, it places 
the patient in very grave danger of early metastasis. In other 
words, the occurrence of metastasis in cancer of the rectum is not 



780 CLINICS OF JOHN B. MURPHY 

SO much a matter of the age of the growth as it is a matter of its 
lymphatic supply. 

We are surrounding this loop of sigmoid with nosophen gauze 
merely to steady it. The actual support of the loop comes from 
the rectus aponeurosis beneath it 

In the combined abdominal and perineal operation or in the 
Kraske operation one is able to take out more of the connective 
tissue in the neighborhood of the sphmcter ' than by the other 
technics. That method should improve the permanency of the 
cures, judging from an a priori standpoint; but whether it will 
very materially improve it will be settled by the test of time. 

[Note. — The patient made an imeventful recovery from this 
operation. The bowel was opened on the third day. Three 
weeks later the radical removal of the growth was carried out by 
the sacral route. — Ed.] 

CARCINOMA OF RECTUM (SECOND OPERATION) 



COMMENTS AND OPERATION 

Dr. Murphy (May 12, 1914): [Incision. Freeing of 
coccyx and lower sacrum. Excision of coccyx.] We have now 
removed the coccyx; the tumor lies clearly in view. We first 
dissect down on both sides of the rectum and free the latter from 
its surroundings. We next dissect below and aroimd the anus 
and then clamp the anus shut with volsella forceps, to prevent 
the fecal contents from escaping during the subsequent proce- 
dures. It is no easy task to free the rectum and pull it down. 
It makes one wonder how a surgeon could pull out 18 inches of 
the large intestine when cureting the uterus. 

Let the record show that we exposed the peritoneum but did 
not open it; that we first exposed the coccyx and sacrum and 
excised the two lower segments of the coccyx; that we thus ex- 
posed the rectum above the levator ani and then freed it from 
its attachments; that after elevating and examining it to de- 
termine the extent of the carcinomatous involvement, the rectum 
higher up was also freed from above downward and the attach- 
ments to the levator ani were cut. (This is a much easier way of 



CARCINOMA OF THE RECTUM WITH ULCERATION 781 

removing the rectum than to free it from below upward) ; that 
when we came to the sphincteric zone we passed behind the 
sphincter in the dissection and detached it, then continued dis- 
secting backward and upward, separating the sphincteric portion 
of the rectum and the portion next higher from the urethra and 
prostate. 

Let the record show that the bowel was not opened at any 
time during the whole procedure until the cautery was applied. 
Let the record show that a rubber drainage-tube was sutured 
to the closed upper end of the rectum, so as to provide for actual 
drainage from that point; that there was no packing left in the 
wound cavity after its edges were approximated; that the tube 
was not fastened with a silkworm-gut suture but with a safety-pin; 
that the patient was ordered to bed on a back-rest. 

Let the record show that the patient was placed on the 
opera ting- table in the superlative Trendelenburg position, which 
gave a splendid exposure of the field of operation; that the car- 
cinoma involved almost the entire circumference of the rectum 
above the sphincter; that it was about i>^ inches wide at its 
broadest portion; that we removed the rectum for two inches, 
both above and below the tumor; that we treated the upper 
end of the rectum just as one treats the appendix — ^by clamping 
and cauterizing the stump, ligating it at the Hne where the 
angiotribe had clamped it, and inverted the stump as one in- 
verts the stump of appendix; that we sutured a rubber drainage- 
tube to this stump, to insure free drainage of the wound products. 

The patient already has an artificial anus well located on the 
abdomen, and also has a tube in the lower angle of the sacral 
wound. Therefore the rectum and sigmoid will not lack for 
drainage. An artificial anus is far more easily handled from in 
front than from behind. The opening is directly in view, can 
be easily and thoroughly cleaned, and a cup is readily applied to 
it, and efficiently controls the fecal stream. The bowels move 
once or twice a day, as a rule. There is no reason why the bowel 
movements cannot be passed just as well in front as behind. 
Cleanhness certainly demands the anterior opening, because it 
is constantly in view and in easy reach of the patient. 

[Note. — The patient made a good recovery. — Ed.] 



SARCOMA OF HUMERUS 



raSTORY 

The patient, a married man aged thirty-eight years, entered 
the hospital May 15, 1914. The patient states that on Septem- 
ber 15, 1 9 13, while loading grain, a sack containing a bushel of 
wheat was thrown down to him from a car-door. As he attempted 
to catch it with his right arm the whole weight of the bag and 
contents struck his right shoulder, forcing the arm back from the 
shoulder. This accident caused him intense pain in the shoulder 
and upper arm. A doctor who saw him half an hour later said 
that the arm was strained and dressed it, accordingly, in a sling. 
He wore the sling only a few days, but the arm and the anterior 
shoulder muscles remained very sore and did not improve much. 

Three weeks later, October 8, 1913, while walking across the 
yard, he stumbled on a cable and pitched forward. To recover 
his balance he threw both arms upward and backward suddenly 
and violently. He immediately felt a snapping, accompanied 
by terrific pain, in the right shoulder. He thought the shoulder 
had been dislocated. A doctor saw him half an hour later and 
called it ''only a strain, " as the arm could be Hfted (voluntarily) 
freely in all directions. The doctor moved the arm, since the 
patient could not raise it more than six inches on account of the 
severe pain. The following evening the muscles in the shoulder 
region became *'set." The condition of the shoulder did not 
improve with rubbing and hot applications, so on November 17, 
1 9 13, the patient went to a neighboring city, where a doctor told 
him the ligaments of the shoulder were torn and advised massage 
and hot baths three times a week. On December 6, 1913, the 
doctor applied electricity and continued the treatment, with no 
effect, until December 24, 19 13, when the patient deserted him 
for a '' chiropractic," who "adjusted his spine" and gave him fur- 

783 



784 CLINICS OF JOHN B. MURPHY 

ther electric treatments. On January i, 19 14, this chiropractic 
forced the patient's extended arm up above his head. This 
movement caused terrific pain in the shoulder. The shoulder 
still remained painful, however, so on February 5th the patient 
consulted a ''neuropathist," who massaged and manipulated the 
arm. The patient thereafter experienced some relief. 

On April 8, 1914, while at a lecture, he removed his coat and 
attempted to swing it over the back of a seat with the sore arm. 
He again felt a snap in the shoulder, accompanied by severe pain. 
Since this time a rapidly enlarging prominence has appeared on 
the shoulder. During the last three weeks the shoulder has be- 
come particularly tender and painful. 

The patient has worked every day since the injury, in Sep- 
tember, 19 13, and has used the affected arm daily in shaving since 
then. He has felt otherwise in the best of health during all this 
time. 

COMMENTS AND OPERATION 

Dr. Murphy (May 15, 1914): This man has come a long 
distance. He is a private patient, and has very kindly con- 
sented to come to the clinic this morning and tell his story him- 
self. It makes a graphic and instructive medical record by itself. 

Patient: It happened in the middle of September. My 
business is grain inspection. I was in Winnipeg at the time, 
inspecting car-loads of grain during the unloading. I told a lad 
who was unloading to throw me down a bushel sack of wheat. 
It went over a little too far and strained this arm (the right). 
[That is, the boy threw the bag too high and to the right, and the 
patient strained his arm in the effort to catch the heavy bag at 
this unfavorable angle, but the bag did not strike the shoulder, 
contrary to the intern's statement in his history.] Three weeks 
later, while I was again inspecting grain, my foot caught in a 
cable as I was walking. I was thrown with such force that I 
dropped on one knee. At the same time I dislocated one of the 
vertebra? in my back, so the doctor [the chiropractic] afterward 
told me. I threw both my arms back to keep from falling on my 
face, and in doing so injured my right arm in some way. I sent 




243- — Sarcoma of the head of the humerus. Before operation, 
bulging of the tumor beneath right deltoid muscle. 



Note the 



VOL. Ill — 50 



785 



SARCOMA OF HUMERUS 787 

for a doctor at once, who said there was nothing wrong with it. 
He told me it woidd soon be all right and to carry it in a sling and 
rub it with some liniment. I stayed at work for a month after 
that, finished up my work, and went in to Winnipeg about ^ve 
weeks after the second injury. There I went to see another 
doctor, who also gave me a prescription for a liniment. 

Dr. Murphy: Did he make an a;-ray picture? 

Patient: No, doctor. After he saw that the liniment was 
not doing much good, he took a little electric machine of his and 
tickled the arm up with that. Then he told me to have the 
arm massaged. The arm seemed all shrunken up and the hand 
too. It would take fifteen minutes for the blood to get back in 
the arm after he put on the electric instrument. Then I went 
to a man and got the arm massaged and he never discovered it 
was broken. Then I went to another doctor who put me through 
a lot of motions and pulled the arm straight up Hke that [indicat- 
ing]. That I think was when the bone dropped down. Up to 
that time it had been above. He said, "That arm will be all 
right if you get it massaged for a couple of weeks. " He did not 
take an a;-ray picture. Then I came up to Moose Jaw and saw 
still another doctor. He did not do it any good, although I 
stayed there until the eighth of April. Then I went to another 
doctor. 

Dr. Murphy: Was he an osteopath? 

Patient: He was everything, doctor. He said that the 
circulation needed stimulation. He was the one who found out 
about my back, and said, "A vertebra in your back is dislocated.'* 
He gave the back a pull and put the vertebra into place. The 
last man has stimulated the arm. The arm is now practically 
all right except for the fracture. The muscle is good, — as hard 
as it ever was, — and the circulation is good. I have suffered a 
lot of pain since the middle of February. I do not think I have 
slept a whole night through since then. 

Dr. Murphy: We are very much obliged to you for telling 
that story in a clean-cut, honest way, and for refraining from a 
possibly justifiable criticism of your doctors. How was your 
condition the day after you caught the sack of wheat? 



y88 CLINICS OF JOHN B. MURPHY 

Patient: The arm felt just a little strained. 

Dr. Murphy: You were able to use your arm every day dur- 
ing the three weeks between the first and second injuries, but the 
arm did not feel so comfortable as the other. Is that correct? 

Patient: Yes, doctor. 

Dr. Murphy: What does that mean? That he did not then 
have a fracture of his arm; had he had a fracture then, he could 
not have used his arm. The first doctor was right. The patient 
did not have a fracture of his arm at that time. Of course not. 
Tell us about the second injury. You went along for three weeks, 
then caught your foot in the cable, and what happened? You 
strained yourself by throwing both hands back to save yourself 
from falling. Is that correct? Where did you have the pain 
after that accident? 

Patient: I said to my assistant that I thought my arm was 
dislocated. 

Dr. Murphy: But you had no pain between the first and 
second injuries? 

Patient: None. Only a little stiffness. 

Dr. Murphy: It was not so freely movable as the other arm? 

Patient: No, not nearly. 

Dr. Murphy: When did you notice that big bunch there on 
the shoulder? Was it the next day? 

Patient: I cannot say when it was. 

Dr. Murphy: What is the matter with him? He did not 
fracture his arm in either of those accidents. He has a sarcoma 
of the upper end of the humerus, which probably started from 
the original injury. The last man who examined it — the man 
who extended his arm so forcibly — may have produced a patho- 
logic fracture. You did not do it — the doctor did it, and, never- 
theless, he is not responsible for your condition. If you had had 
aU the doctors in the world work on that arm it would not have 
been a whit better today than it is unless some one of them had 
made the correct diagnosis of your trouble and operated. 

The diagnosis can now be made from his story. He was well 
after the first injury and a little less well after the second. Fi- 
nally the shoulder commenced to enlarge and become painful 



SARCOMA OF HUMERUS 789 

and then more painful, and larger and still larger. Now, the 
moment you look at that shoulder you know it contains a malig- 
nant tumor. The malignant lesion appears to be the sequence 
of the original trauma when the patient strained his arm in 
grasping the sack, because the shoulder never got well after that 
injury. The original injury was not a fracture. A sarcoma 
practically never develops as the sequence of a fracture, although 
a pathologic fracture is rather frequently the result of a sarcoma. 
This patient has now a pathologic fracture producing separation 
of the head from the neck of the humerus, as you see it here in 
the x-ray plate. The doctor who pulled the arm did not do him 
any special injury. The fracture imdoubtedly would have 
occurred sooner or later, in any event. 

Let us come back to the role the doctors played in this case. 
The patient gave the regular profession the first chance, a second 
chance, and a third chance, and only then did he go seeking false 
gods, as he was justified in doing after the three failures chalked 
up against the disciples of Minerva Medica. He had a chiro- 
practic work on his spine and he felt better as the result. The 
chiropractic, of course, could not make the diagnosis, but he was 
less blameworthy than the members of the regular profession 
who did not make it. The diagnosis could have been made by a 
careful consideration of the patient's story, by a careful examina- 
tion, or by an x-ray plate. That is what I want to bring out. 
It was not made, although it could have been. 

The sad part of this case is that nearly three-fourths of a year 
has elapsed since this sarcoma began, and in that three-fourths 
of a year the patient may have lost the opportunity of saving his 
life. What we shall advise him to do is to have an excision of 
the head and upper half of the humerus. Then, after the wound 
from the first operation is healed, we shall transplant a piece of 
bone from the crest of his tibia to supply the defect. We can 
remove the local disease, we believe, just as completely by an 
excision as by an amputation. That is, we will be able to re- 
move all the tumor tissue just as safely by excision and dissec- 
tion as if we did an amputation. His arm below the site of 
operation will remain good and useful. If he already has metas- 



790 CLINICS OF JOHN B. MURPHY 

tases, — ^and the man who gave the last jerk in pulling the arm 
may have started these malignant cells on their fatal way to the 
lung, the spine, the spinal cord, or the brain, — then he will still 
get just as much benefit from an excision as he will from an am- 
putation. He will consent to an excision at once. He will not 
now consent to an amputation. Why? Because he has already 
had four or five doctors go wrong on his case, therefore why 
should he not expect us, too, to be in error. Why should he 
sacrifice his arm on the opinion of one man whose professional 
colleagues have told him a wrong story before? He will accept 
our opinion to a certain degree, but not to the extent of allowing 
us to remove the arm. He would probably wait imtil metastases 
developed before he would consent. He is justified, we believe, 
in having some doubts about us. If he will give us his consent 
for operation, we will operate on him tomorrow. We have some 
heavy cases for tomorrow, but we feel that no time should elapse, 
now he has once come under our observation, until something is 
done for him. By "something" we mean the wide excision of 
his tumor. 

[The patient promptly gave his consent to the excision of the 
tumor, and entered the hospital the same afternoon. The in- 
tern then wrote the history which heads this case report, and read 
it the next morning just before Dr. Murphy started to operate 
on the patient. — Ed.] 

Stenographer (May i6, 19 14): [Reads off verbatim the 
patient's story as he related it to the clinic on May 15th and as it 
appears above.] 

Dr. Murphy (May 16, 1914): That is the man's statement, 
just as he talked it off yesterday without prompting and without 
assistance. Now I will have the doctor read his history. 

Intern: [Reads history.] 

Dr. Murphy: What date was it that he felt that last snap? 

Intern: April 8th. He was attending a lecture, and, in 
removing his coat, he felt a snap in his shoulder. 

Dr. Murphy: That is a point in addition to what he gave us 
yesterday. The strain in removing his coat may have fractured 
his arm. The strain of removing a coat is not enough, of course, 



SARCOMA or HUMERUS 79 1 

to fracture a normal shoulder. If this was a fracture, it was a 
pathologic fracture. From this time on the tumor grew more 
rapidly, although there was aheady some evidence of the exist- 
ence of the disease even in September, 19 13. The patient came 
in here with considerable feeling against his first doctor for 
having overlooked a fracture, as the patient unjustly thought. 
An x-ray picture was not made until shortly before he came here. 
The doctor who made the plate thought this was a simple frac- 
ture of the shoulder and sent him here to have it repaired. The 
patient has a fracture of his shoulder, but it is a pathologic 
fractiure. 

When you look at our rr-ray picture here, you will note that 
the head lies in about the normal relationship to the glenoid 
cavity. The patient had as his original injury a strain of his 
shoulder. That may have pulled off some of the Kgamentous 
attachments of the humeral head, thus furnishing the stimulus 
for the growth of the sarcoma. In the last number of the 
Clinics there are a number of illustrations of these pathologic 
fractures occurring with mild traumas, as positive indications of 
disease processes in the bone antedating the fracture. That is 
what led to this man's fracture. 

Now that we have determined that this tiunor is a sarcoma, 
we should like to know what type of a sarcoma it is. I do not 
know. From the rapidity of the growth I am fearful that it is 
the roimd-cell variety arising from the periosteum. If it is 
the round-cell variety, has it already passed into the circulation, 
and has he multiple round-cell sarcomata in different positions 
in the body? If he has any metastatic foci, they are still too 
small for us to find, because we have searched for them carefully 
by physical examination and with the a;-ray. 

If he survives the two operations, as we have every reason to 
think he will, and has no recurrence in loco, he should be cured 
of his disease, as have been a number of these cases whom we 
have had up to this time, including both metastatic sarcoma and 
carcinoma. If he already has metastases, he has lost nothing 
by having the local operation. 

We have a patient now in the hospital who is about ready to 



792 CLINICS OF JOHN B. MURPHY 

go home, who had a carcinoma of the breast, following the ex- 
cision of which she developed a metastatic carcinoma in the 
trochanteric region of her femur. We excised the head, tro- 
chanter, and several inches of her femur at the first operation. 
When the wound was completely healed, we transplanted a piece 
of bone from the crest of her tibia to substitute for the excised 
upper end of the femur. If she has only the one metastasis, she 
should live and get a useful leg. If she has others, she has lost 
nothing by the operation. She would not consent to an amputa- 
tion, and an amputation would have had no great advantage over 
the local removal, in our opinion. 

We have one case coming here now for sodium cacodylate 
injections and rc-ray treatment, from whom, some two years and 
eight months ago, we removed the trochanter head and upper 
shaft of the femur for sarcoma and transplanted a piece from his 
tibia into the defect. He is able now to bear his whole weight 
on the leg, although he still walks with crutches as a precaution 
against injury. He has no return of the sarcoma at the site of 
operation, but he has developed metastatic sarcoma on his scalp, 
in his lung, and in numerous other locations. We have been 
unable to demonstrate metastases in any of the other bones of 
the body. The sarcoma of the femur was not operated until 
two years and six months after it first gave symptoms ! 

We cannot treat these malignant diseases of the bone suc- 
cessfully until we treat them early. The patients will consent 
early to the operation of excision, but they will not consent to an 
amputation early in the disease. They just travel from one 
doctor to another. You need not wonder that they do so, in 
view of the experiences which this patient has had. 

The manipulation to which this shoulder has been subjected 
is one of the dangerous elements in the case and does not exist 
in the average case of sarcoma. It makes the outlook very grave, 
because of the great likelihood that cell-masses have been de- 
tax:hed by the physical measures used. If he had not had the 
misfortune to be manipulated by the osteopath and the chiro- 
practic, he would have less prospect of fatal dissemination than 
he has now. We must in justice to them say that dissemination 



SARCOMA OF HUMERUS 793 

is one of the things which can and does occur without their as- 
sistance. 

Whether we shall do a primary transplantation now or 
whether we shall wait for two or three weeks to let the wound 
of the first operation heal before performing the second will 
depend altogether on how completely and easily we get this 
tumor out. In the carcinoma case we did not transplant the 
piece from the tibia until four weeks after we performed the 
excision of the hip. 

Our plan of procedure is the following: We shall make the 
skin incision along the anterior margin of the deltoid and then 
dissect down on the head and neck of the humerus through a 
comparatively ^'neutral zone," in which we have to divide no 
large vascular or nerve-trunks. The posterior circumflex vessels 
and the circumflex nerve (N. axillaris) approach this zone from 
the rear, and the anterior circumflex vessels and the branches 
of the thoracic axis (A. thoracoacromialis) from the front. The 
cephalic vein which we come upon at once at the anterior border 
of the deltoid we dislocate lateral ward with the deltoid. There 
are no large nerve-trunks endangered until we descend along the 
humerus to the musculospiral. 

By rotating the humerus strongly inward all the external 
muscle insertions come into view and are divided, but kept under 
control by hgatures and forceps; and by external rotation all 
the internal muscle insertions come into view, are divided and 
controlled. Then we divide the capsule, turn the head out of the 
joint, and free and excise as much of the humerus as we desire. 

[Incises the skin.] 

We make the skin incision over the inner margin of the' 
deltoid and dissect down over the long head of the biceps. [Many 
small ''bleeders" were cut and promptly caught. These are 
some of the terminal branches of the circumflex vessels and 
thoracic axis.] Now we shall cut across the deltoid above and 
throw it away from its clavicular attachment. Now let us 
see how far this tumor has penetrated to the outside. It rather 
looks and feels to me now as though it had grown out beyond the 
capsule. If it has, that will practically preclude the continuance 



794 CLINICS OF JOHN B. MURPHY 

of the procedure. The diagnosis, you see, is already, unfortu- 
nately, too much confirmed. We are dissecting down now along 
the inner margin of the deltoid to its insertion into the humerus. 
Now we are coming to the line of insertion of the pectoralis 
major muscle into the spina tuberculi ma j oris. The other 
muscles which are inserted into the humerus from this side are 
the coracobrachialis and short head of the biceps, attached to 
the coracoid process, and the subscapularis, which is inserted 
into the lesser tuberosity. Now I shall divide the long head of 
the biceps between these two hemostats. Now I am close to 
the capsule of the joint. There is the supraspinatus muscle 
inserted into the greater tuberosity. I am attaching all these 
muscles to long sutures as I cut them, so that at the close of the 
operation I can suture them together properly. 

I shall free the attachment of the deltoid to the acromion 
and to the outer portion of the clavicle, and swing it downward. 
I am going down to the attachments at the shoulder. The ob- 
struction to rotation presented by the tumor itself is very con- 
siderable — ^a mechanical obstruction. That lets me come in 
fairly well on to the head. Now I am in the joint. Now I am 
going forward to the attachment of the subscapularis, which is 
the muscle which prevents the head from making external rota- 
tion at this point. That is the subscapularis tendon on my 
finger. I will secure it over these other muscles with the hemo- 
stat, because I wish to control its subsequent position. Now I 
am able to come along down the capsule, detach the remaining 
portion of the pectoraUs major, and make external rotation of the 
humerus. There is the brachial artery. Now I shall proceed 
to the under surface of this capsule and divide it. We luxate 
the head entirely out of the joint. We detach the insertion of the 
infraspinatus. You will note that in our dissecting so far we 
have carried out all our procedures in strict conformity with the 
vascular supply of this region. I am able to swing out that 
humerus by having followed a definite plan. Now we push up 
the shaft. We pass down here along the shaft in our dissection 
as far as we desire, and endeavor to keep away from the circumflex 
vessels and nerve and the musculospiral nerve lower down. There 



SARCOMA OF HUMERUS 795 

is the musculospiral, I take it, coming up behind. There is the 
remaining portion of the insertion of the pectoraUs major. The 
long head of the triceps now comes into the field. When I was 
working at the inner side of the field, dissecting free the attach- 
ments there, the task looked a Kttle bit difficult. Now it already 
appears easier. We shall detach the humeral head of the triceps. 
Now I return the head of the bone to the joint for a moment to 
get my bearing as to the position of the arteries and nerves. 
Now I turn out the humerus agaiu, retract all the soft parts, and 
divide the humerus about halfway down the shaft. That looks 
Hke a normal medulla which I have opened, and I am well 
beyond all visible evidence of tumor tissue. That was not such 
a difficult task, because we had our campaign mapped out and 
were able to follow the plan. The greatest muscular attachment 
comes from behind. We just split that off at the bone. 

Let the record show that the attack on the joint was made 
from in front; that we first detached the upper anterior clavic- 
ular portion of the deltoid muscle, then split the deltoid muscle 
parallel to the long axis of its anterior fibers, and went through 
in relationship to the structures below; that we hoped to be able 
to rotate backward the tumor after dividing the long head of the 
biceps, the coracobrachiaHs, and the pectoraHs major; these are 
the muscles that prevent external rotation. 

[The upper end of the humerus containing the tumor is sawed 
in half and demonstrated to the clinic] 

The tumor began in the periosteum apparently and extended 
into the bone. It did not involve the capsule because, as you 
see, it does not attack tendon tissue readUy. Now we are 
securing each detached muscle with a ligature on its end, so as 
to tie them en masse, and have them in position there for subse- 
quent fixation to the transplant, whenever we decide to perform 
the secondary operation. 

There is probably a metastasis somewhere in this man's 
body, judging from the course he has followed and from the 
considerable extent of the medullary involvement; but it would 
not be fair to him not to give him an opportunity of escape from 
certain death unless this local condition is removed, even though 



796 CLINICS OF JOHN B. MURPHY 

he avoids this peril only to perish later from metastases. He will 
immediately be put on large doses of sodium cacodylate and on 
large doses of a'-rays. The cacodylate will be given in doses of 
3 grains daily hypodermatically, later increased to 5 grains every 
second day. 

Now I am inspecting the field to see if there are any diver- 
ticula of the tumor running off in any direction. I can find none. 
Now we tie together all these muscle-ends. These ligatures are 
all on the ends of muscles. I tie them together ew masse, as that 
fixes them in a definite position, so that subsequently, when I 
come to transplant a piece of the crest of the patient's tibia to 
fill the defect, they will all be outside of the capsule and ready 
for attaching to the transplant. 

Let the record show that we sutured all the severed muscle- 
ends together across, and in about their normal relationship to, 
the cavity which remained after the removal of the tumor; that 
we united the subscapularis to the infraspinatus; that we united 
the pectoralis major and the latissimus, on the inner side, to the 
stump of the infraspinatus on the outer side; that the supra- 
spinatus was attached to a portion of the biceps to hold it down; 
that the deltoid was pulled forward with the pectoralis major 
to cover the field. 

Let the record show that the loss of blood was not great, 
considering that the excision of the tumor was apparently com- 
plete; that we were able to keep just outside the joint capsule 
in our dissection, although excising all the tumor. 

Let it show further that the tumor began in the periosteum; 
that it extended up and down from the periosteum and into 
the bone-marrow; that there was considerable rarefaction and 
absorption in the bone involved, and, as the result of this change, 
a pathologic fracture through the zone of invasion. 

That is a beautiful clinical history — just the story of what 
happened, you see, makes the diagnosis. The last doctor, the 
one who examined the shoulder with the ic-ray, found it fractured. 
He believed that the fracture was the sequence of either the first 
or the second injury. The first injury, we believe, started the 
sarcoma. His first doctor, against whom he has considerable 





B 
Fig. 244.— Sarcoma of the head of the right humerus, originating in the peri- 
osteum, invading the medullary cavity, but not penetrating the capsule of the joint. 
A , External view of the tumor and resected humerus. The cartilage on the articular 
surface of the humeral head has not been penetrated by the tumor. B, Tumor and 
humerus split longitudinally, showing the medulla of the head and neck of the 
humerus involved by the tumor infiltration, but the diaphysis containing normal 
fatty marrow. 



797 



SARCOMA OF HUMERUS 799 

animus, is not at all responsible for his present condition, and we 
told the patient so yesterday with great explicitness. [Demon- 
strates again the gross pathologic specimen.] 

There is the line of fracture. You see it is thoroughly in- 
filtrated by the tumor. You see the tumor appears to have 
taken its origin at about the insertion of the supraspinatus into 
the periosteum. The supraspinatus is the muscle which he 
would be likely to injure, you can see, with external and backward 
hyperrotation and hyperextension of the arm, because the supra- 
spinatus is attached to the greater tuberosity. It looks from 
this gross specimen as though that was the primary focus of the 
tiunor and that thence it extended into the medulla of the bone. 

[Note. — The patient made an uneventful recovery from this 
extensive operation, save that a hematoma formed which had to 
be aspirated two or three times. Six weeks later the second 
operation was performed. — Ed.] 

SECOND OPERATION 

EXPLORATION OF SITE OF THE PREVIOUS OPERATION PRE- 
PARATORY TO TRANSPLANTATION OF A PIECE OF 
THE TIBLA. TO THE HUMERUS 

Dr. Murphy (June 29, 1914) [Incision along the anterior 
margin of the deltoid] : I shall cut down on the field of the pre- 
vious operation by following the inner margin of the deltoid. 
The anatomic relations are entirely different now from what they 
were in the beginning of the previous operation. I sutured all 
the muscles of the shoulder together at the original operation, 
bringing the opposing muscles together into a central line of 
union, into which I expect to graft a transplant from the tibia 
in case there is no local recurrence of the tumor. I am carrying 
my dissection somewhat inside the inner margin of the deltoid, 
but not so far inward as at the previous operation, because the 
vessels and nerves now lie a httle further outward than before. 

[Cuts down upon a mass of soft, friable, grayish-red material 
near the attachment of the pectoralis major to the central mass, 
about the site where the sarcoma led to fracture of the humerus, 
previously.] 



8oO CLINICS OF JOHN B. MURPHY 

I think this is a return of the trouble. I cannot tell for 
certain whether it is an organizing hematoma or a sarcoma, but 
it looks rather more like a sarcoma situated in the soft parts. 
I shall close the woimd and wait for the final report of the path- 
ologist before undertaking any further operative procedure. 
If this is a sarcoma, it will not do the patient any good to have 
the arm amputated — not a particle. He will have metastases 
in his lung and in other positions in the body just the same. He 
is looking fine, feeling well, and gaining in weight, but that does 
not mean much in such a case of sarcoma. During all this last 
year, while the sarcoma has been growing, he was also feeling 
perfectly well, except for his arm, and he has been working at 
his usual occupation. This recurrence, for such I believe it is, 
does not show in the ii;-ray plate at all, of course, because it lies 
entirely in the soft parts and contains no osseous material. The 
shoulder has been aspirated two or three times to remove the 
hematoma which formed after the operation. We shall manage 
this case on just the same plan as we did the last case of carcinoma 
of the hip, which we excised. (See Clinics for June, 1914.) We 
shall wait for the pathologist's report, not from an examination 
of the frozen section merely, but his final definite report, based 
on the careful study of a series of paraffin sections. If that tissue 
proves not to be a sarcoma, then tomorrow morning, or the day 
after, we shall put in the graft from the tibia. If it proves to be 
a sarcoma, we shall not do anything further in an operative way 
with him, but shall continue the sodium cacodylate injections 
and the a;-ray treatment. 

Even if this tissue turns out to be a recurrence of the sarcoma, 
it will not alter our confidence in our plan for treating these 
malignant bone tumors by excision. A recurrence, of course, 
is just what we should expect in a sarcoma of this region, which 
has been managed as this case has been. The massage, the 
manipulations, and, finally, the fracture, all have tended to 
scatter broadcast the malignant cells. With the present ad- 
vanced information which we obtain in tumors of the bone 
through the use of the x-ray we should deal with bone tumors on 
an entirely different basis from that on which they were treated 



SARCOMA OF HUMERUS 8oi 

preceding the era of the x-ray. It is our conviction that the 
chapter on treatment of mahgnant bone tumors should be re- 
written radically and promptly in our surgical text-books. 

Let the record show that the sponge, saturated with 5 per 
cent, carbolic acid, with which the wound was swabbed out, was 
removed from the cavity. 

Let the record show that on cutting down on the site of the 
previous operation we foimd a mass of granulation tissue re- 
sembling sarcoma on the under surface of the deltoid muscle; 
that we scooped out this tissue and sent it to the pathologist for 
microscopic examination; that we then closed and dressed the 
wound, awaiting the report of the pathologist. 

Within twenty-foiu: or, at the most, forty-eight hours we 
shall have his final report. If the specimen proves to be only 
granulation tissue, we shall then take out the stitches and make 
a transplant from the tibia. If this proves to be a return of the 
sarcoma, we shall do nothing in an operative way. 

[Shows a patient with multiple sarcomatous nodules in the 
skin, marked bilateral exophthalmos, and beginning cachexia.] 

Here is another somewhat similar case. This patient had a 
traumatic sarcoma involving the trochanter major. He was 
operated and the tumor excised two years and seven months 
after the injury, which marked the beginning of his sarcoma, or, 
at least, the time since when his hip has continually bothered 
him. We took out all the tumor two and a half years ago, to- 
gether with the head and neck of the femur, and replaced it with 
a transplant from the tibia. Since the operation the transplant 
has so increased in size as to carry his entire weight. Six months 
ago he showed the first evidence of a metastatic growth. The 
sarcoma nodules first appeared in his lung. Now he has multi- 
ple sarcomata all over his body and is going to die from his 
sarcoma. But he has no evidence whatever of a return of the 
tumor in the femur, thus demonstrating that such a local lesion 
can be and was actually, in his case, completely eradicated. If 
the local lesion can be eradicated, the disease can be cured if 
attacked in the early stage, before metastases have occurred. 
We have reason, therefore, to hope, but it is only a hope, for a 

VOL, III — 51 



802 CLINICS OF JOHN B. MURPHY 

cure in all these cases eventually. No one has settled yet how 
early metastasis takes place after the primary deviation from 
the normal in the pathologic connective-tissue cells in the case 
of sarcoma, or after the primary penetration of the basement- 
membrane by the aberrant epithelial cells in carcinoma. Empiri- 
cally, however, and largely from a cHnical standpoint, we have 
some evidence bearing on this question. We can say that the 
malignant tumors which are removed in the early stage of the 
disease run a much smaller percentage of metastasis than those 
tumors which are removed late. We have, probably, a right to 
assume that there is a period between the time of penetration of 
the basement-membrane in cancer and the time of its regional or 
distant metastasis. We have had a little Hght thrown in this 
direction recently by the Cancer Research Institute in Boston, 
an afl&liated institution of Harvard University. In the Jensen 
mice and in the Japanese waltzing mice it was found that cancer 
metastasis takes place fairly regularly on the thirty-ninth day; 
that there appears to be a period between the time of inoculation 
or transplantation of the cancer and the thirty-ninth day, during 
which the tumor regularly remains a local disease; that in that 
period there is usually no evidence of metastasis. It is on the 
presumption that there is a similar period of early focal restric- 
tion in human cancer that we base our expectation of improved 
results in the removal of these malignant bone tumors. We 
hope and believe that the local stage of cancer in the human is 
distinctly longer than in mice, but we have as yet no definite 
basis for this conviction. 

Another interesting fact brought out in the same work was 
that hybrids from these two mice, the Jensen mouse and the 
Japanese waltzing mouse, only in the first generation were cap- 
able of cancer infection by implantation of the carcinoma. In 
the first generation of hybrids one can transplant the Jensen 
cancer with practically loo per cent, of positive results, while 
in the second generation of hybrids not one single case of suc- 
cessful implantation was obtained. That is an interesting ob- 
servation. This crossing produces merely a family deviation, 
not a true hybrid at all, but the striking and radical alteration 



SARCOMA OF HUMERUS 803 

in reaction to cancer implantation thereby produced is completely 
in consonance with our experience with the transplantation of 
normal tissues. Minute differences in racial origin produce gross 
differences in the reaction to tissue transplantation. For in- 
stance, the transplantation of an ovary from one white woman to 
another in a large percentage of the cases fails to live, as shown 
by Tufiier. The transplantation of a woman's ovary to her own 
subcutaneous cellular tissue in a large percentage of the cases 
lives; but the transplantation of ovarian tissue from a white 
woman to a black woman or from a black to a white woman 
always dies. This, you see, is about the same racial deviation 
as in the mouse cancer transplant. The moment one tries to 
transplant normal tissue, either out of the family or even out of 
the individual, one fails to secure a successful implantation, as 
a rule. With cancer tissue in mice, however, one gets nearly 
uniform success in transplanting from one mouse to another of 
the same race. 

[Note. — ^The stitches were removed on July 7, 19 14. He is 
to contiQue with the oj-ray treatments and the cacodylate injec- 
tions. The pathologist, Dr. Sweek, reported that the excised 
tissue is a recurrence of the sarcoma, the cells here being more 
round in type than in the original tumor, corresponding to their 
changed environment. Such morphologic reactions of tumor 
cells to environmental alteration have been repeatedly described 
by Ribbert, Herzog, and Flexner and Jobling. — Ed.] 



CEREBELLAR TUMOR.— SUBOCCIPITAL DE- 
COMPRESSION 

DISCUSSION OF NEUROLOGIC SYMPTOMS BY DR. 
CHARLES L, MIX 



HISTORY 

The patient, a man forty-four years old, entered the hospital 
with the following history : His mother died of carcinoma of the 
stomach twenty years ago. There is no history of tuberculosis 
in the family. 

The patient states that seven years ago he fell, striking his 
head on a stone. He was unconscious for a few minutes, but 
never had any subsequent trouble attributable to the accident. 
Three years ago, while lying in a barber's chair, he was seized with 
a speU of dizziness for the first time. Since then he has had many 
attacks, especially when lying on his back. The dizziness is re- 
lieved somewhat, as a rule, by turning on either side. This 
dizziness lasts for only a few minutes at a time, but he has several 
attacks a day. Immediately after eating he sometimes vomits, 
but without any preceding nausea. He developed about the 
same time (191 1) a continual dull headache, from which he could 
get no relief. The dizziness gradually grew worse, and the 
headache also continued imtil January, 1914. Then the head- 
ache became somewhat less severe. The patient has been able 
to attend to business until the present time. He cannot walk 
without the aid of a cane or some one taking him by the arm. 
Since January, 19 14, he has had to give up riding in an automo- 
bile on account of the jar causing him pain in the head. The 
pain seems to run from the parietal eminence down the neck, and 
is of a pricking character. 

About December, 1913, he noticed that he could not see ob- 

80s 



8o6 CLINICS OF JOHN B. MURPHY 

jects as well as formerly, unless directly in front of him. He 
had to change the position of his head in order to see objects 
clearly. Sometimes objects appeared double to him. There 
does not seem to be any obvious paralysis of the muscles of the 
eye at the present time. At first vision was worse in the left eye, 
but at present vision is about equal in both. He says that 
while riding he cannot recognize people in the street. His pupils 
react to both light and accommodation. 

While in a sanatorium in January, 19 14, a spinal puncture 
was made, but did not relieve the dizziness. A Wassermann 
test was made, but was negative. He states that he has had no 
paralysis at any time. His knee-jerks are present on both sides. 
There has been a continual collecting of mucus in the back of the 
pharynx ever since his trouble began, three years ago. Since 
August, 1 9 13, his tongue has felt thick and there has been some 
husldness in talking. He also has some difficulty in swallowing, 
as the food seems to collect at the back of the tongue. This 
failure of the food to pass on causes coughing, which is very pain- 
ful at times. 

Since entering the hospital he once got out of bed to go to the 
door and fell on the way. He was fully five minutes regaining 
his feet and getting back into bed. At present his headache is 
not so severe as formerly, but the dizziness is continually growing 
worse. 

COMMENTS AND OPERATION 

Dr. Murphy Qune 9, 19 14): Where did the stone strike his 
head? 

Intern: He fell on the stone. 

Dr. Murphy: Yes, but where on his head was the injury? 
If you fell on the floor, it would make a difference whether you 
fell on your face or on your occiput. 

Intern: He did not know. 

Dr. Murphy: You should have found out whether he struck 
on his forehead or on his occiput. He knows which way he fell, 
just as well as he knows that the stone struck his head. Was he 
unconscious? 



CEREBELLAR TUMOR. — SUBOCCIPITAL COMPRESSION 807 

Intern: He was unconscious for a few minutes. 

Dr. Murphy: That is an important point to have in the 
history, the fact that the lapse was only a few minutes in dura- 
tion. Did he first become unconscious, then conscious again, 
and, finally, lapse again into unconsciousness, which is so com- 
monly the case with a middle meningeal hemorrhage? With a 
middle meningeal hemorrhage the patients, when struck, are 
stunned, then get up, go about, and gradually become a little 
languid, then a little stupid, and finally pass again into uncon- 
sciousness. That is the typical and classic history of a middle 
meningeal hemorrhage. The sequence did not occur here, 
according to the doctor's story. I do not know the case well 
enough myself to criticize what I am told. All I can do is to ask 
questions. Dr. Mix has made a careful neurologic examination 
of the patient, and will analyze the case from a neurologic stand- 
point. 

Dr. Mix: The patient is forty-four years of age. The fall 
which he had seven years ago, in which he struck his head upon a 
stone, rendered him unconscious merely for a small period of about 
five minutes. He recovered from this slight trauma without any 
particular symptomatology following it, and proceeded to forget 
the whole matter until his present disturbance appeared. Then, 
on being asked whether there was any previous history of injury 
in his case, he recalled this accident of seven years ago. 

His first real trouble seems to have begun when he was in the 
barber's chair about three years ago. He was lying back while 
being shaved and suddenly became very dizz5^ On looking back 
over his case he attributes the dizziness which then occurred to 
the trouble which he has now in his head, and he insists that that 
dizziness marked the beginning of his present trouble. The 
vertigo persisted for quite a long period of time without any asso- 
ciated symptoms — perhaps for nearly two years' time. During 
the last year or so vomiting has been added to his s)miptoma- 
tology, and of late, particularly since January ist, he has been 
very much disturbed by his symptoms. In January he went to 
the Sacred Heart Sanitarium in Milwaukee, and there a lumbar 
puncture was done. He overheard the physician who made the 



8o8 CLINICS OF JOHN B. MURPHY 

puncture say that the fluid spurted out in a stream and that it 
was under a great deal of pressure. We have learned that the 
diagnosis of "syphilitic gumma" was made, and that he was put 
on large doses of iodid of potash, being given as much as 95 grains 
at a dose three times a day. There was no improvement; if 
anything, he was even made worse. 

During the last half of the year 1913, headache was quite a 
feature in his symptomatology, but there was not very much 
vomiting. The patient himself says that he does not vomit. 
He says he "gulps up" his food. Many patients with cerebral 
tumors do not show the symptom of projectile vomiting, but in- 
stead gulp up small amounts of food without nausea, and, as one 
patient expressed it to me, he *^ would gag after eating break- 
fast" or, perhaps, during his breakfast; and, often, after gagging 
he would go on and complete his meal as if nothing had happened. 
Such a type of vomiting is quite as characteristic of a cerebral 
neoplasm as is the better known projectile vomiting. 

Besides these disturbances that are spoken of in the history 
he has another set relating to vision. He began to have trouble 
with his eyes in January, 19 14. When he was in Milwaukee at 
the Sacred Heart Sanitarium he consulted an oculist about his 
eyes. Previous to that time he had consulted a physician in 
this city, who found a ptosis of the left eye as the only finding, 
and had looked upon the case as syphilitic. In January the 
oculist examined his eye-grounds, previously examined and found 
negative by another ophthalmologist, and discovered there was 
some disturbance of the nerve head. He told the man he could 
not help his vision very much, but that he could relieve his double 
vision by blocking the sight of one eye. This blocking off of one 
eye was very inconvenient to the patient, so that he quickly 
abandoned it. He has gotten along with his double vision thus 
far as best he could. 

Another symptom has lately appeared in his case, and that is 
disturbance in walking. Since early in 19 14 he has been very 
unsteady on his feet. The other day, as you heard in the history, 
when he got out of bed he fell on the floor and he could not get 
up, there being nobody to help him. He estimates that he was 



CEREBELLAR TUMOR. — SUBOCCIPITAL COMPRESSION 809 

upon the floor for nearly five minutes before some one came. 
When on his feet he does not sway to the left or right or backward. 
He does have a tendency to pitch forward. Such a symptoma- 
tology with disturbances of station and gait and a tendency 
to forward pitching occurs when there is disturbance in the work 
of the cerebellum. 

There is another significant fact in his history. Two weeks 
ago he had a respiratory attack of some sort. His breathing was 
very labored. The attack lasted for only a short period of time, 
and was evidently a paroxysm of respiratory difiiculty. It was 
associated at the same time with vomiting. The association of 
trouble in breathing with vomiting may be used as indicative 
of disturbance in the floor of the fourth ventricle, involving the 
nucleus of the pneumogastric nerve. The respiratory center in 
the fourth ventricle Kes, as you remember, in the nucleus of the 
pneumogastric nerve. Recall the cases of death from respiratory 
paralysis in cerebellar tumor, the heart beating on sometimes 
several hours if artificial breathing is kept up. 

In addition to these symptoms he also shows another posterior 
fossa sign. His tongue deviates to the left. When he protrudes 
it, it turns the corner and goes to the left side. Because the right 
side is protruded farther than the left side the latter lags behind. 
Consequently the tip of the tongue turns the comer to the 
left. In other words the patient's left hypoglossal nerve is weak. 
It is possible, although I do not like to commit myself on this 
point, that there is a httle atrophy on the left side of the tongue. 
If so, it indicates a disturbance either in the hypoglossal nucleus 
or in the nerve-trunk. In palpating the tongue on both sides 
with a towel it seemed as though there was a little less tonus on 
the left side of the tongue than on the right. I do not believe, 
however, that there is any marked disturbance of the hypo- 
glossal nerve beyond a mere paresis. Moreover, this paresis of 
the hypoglossal nerve is not a part of a left-sided hemiparesis 
affecting the whole body. 

There is also a very marked disturbance of the external rectus 
muscle on the left side, indicating that the sixth nerve, which 
supplies the external rectus, is partially or completely paralyzed. 



8lO CLDHCS OF JOHN B. MURPHY 

He cannot turn his left eye out because of the paralysis of the 
left external rectus. The right external rectus is in better con- 
dition. He can throw both eyes to the right. 

In addition to the lesion affecting the left twelfth nerve, 
the left sixth nerve and the pneumogastric respiratory center, 
there is also trouble with his left third nerve. He has a left- 
sided ptosis due to a paresis of the levator palpebrae superioris. 
His left pupil is a very little larger than the right, because of a 
paresis of the nerves innervating the iris muscle. A dilatation 
of the pupil on the same side as the ptosis is excellent evidence 
of a paresis of the third nerve. When you place a drop of a solu- 
tion of atropin in a patient's eye for the purpose of dilating his 
pupil, you dilate it by paralyzing the filaments of the third nerve. 
If the third nerve is affected in a patient, the corresponding pupil 
will dilate. This patient's left pupil is dilated. In addition, the 
internal rectus muscle is weak on both the right and left sides. 
We, therefore, are justified in concluding that there is a bilateral 
disturbance affecting both third nerves, but chiefly the left. 

There is apparently no disturbance of the fourth nerve. He 
can innervate his superior oblique muscles on both the right and 
left sides practically perfectly. The seventh nerve is also free 
from trouble on both sides. The patient is able to use the facial 
muscles of expression without the slightest evidence of paresis. 

The first question is the general one of diagnosis. Such a 
history of vertigo, headache, vomiting of the cerebral type, 
associated with disturbances clearly referable to the brain, is a 
fairly certain indication of the presence of an intracranial neo- 
plasm or an accumulation of fluid. It can occur in a tumor of 
any sort or in a hydrocephalus intemus. It cannot occur in a 
meningitis, because meningitis is an acute disease, or, at the most, 
subacute. There being no diminution of the man's mental 
capacity, it can hardly be looked upon as being related to one of 
the diseases of degeneration of the cerebral cortex. The history 
of the increased pressure of the cerebrospinal fluid on lumbar 
puncture is also very suggestive of increased intracranial pres- 
sure, probably due to a cerebral tumor. 

Are there any signs of disease in the spinal cord? None at 



CEREBELLAR TUMOR. — SUBOCCIPITAL COMPRESSION 8ll 

all. He has neither increased nor diminished knee-jerks, ankle- 
jerks, or any other spinal reflexes. He has no spasticity. He has 
no paresis of the upper or lower extremities, trunk, or abdominal 
muscles. On the contrary, he is extremely strong. He has no 
sensory losses, no atrophies, no contractures, no Babinski re- 
flexes, no ankle-clonus or patellar clonus. There is no history 
of disturbances in innervation of either his bladder or rectiun. 
His spinal cord is, therefore, imaffected. 

As to the brain, there is no euphoria, no undue happiness, 
which oftentimes comes with lesions of the anterior portion of the 
frontal lobes. There are no motor symptoms, pareses or par- 
alyses or contractures, indicating disturbances over either his 
right or left motor cortical zone. There is no lack of initiative, 
no extreme lethargy, such as occurs in tumors of the corpus 
callosum. There is no closure of the foramen of Magendie, 
either from the pressure of the tumor or from an old inflamma- 
tory process, as is clearly indicated by the spurt of the cerebro- 
spinal fluid when the lumbar puncture was made. 

There is no disturbance in the middle fossa, so far as I am 
able to tell. There is no symptom associated with disturbances 
of the functions of hearing, smelling, or tasting. There is no 
aphasia of any sort. There is no evidence pointing to a tumor 
involving either of the optic thalami or the hypophysis. 

Passing to the posterior fossa, there is no evidence of a cere- 
bellopontine tumor. There is no unilateral disturbance of both 
the seventh and eighth nerves. There are, however, signs of 
disturbances in the posterior fossa — the staggering gait, the 
tendency to pitch forward, the paresis of the left hypoglossal 
nerve, and the paroxysm of respiratory difficulty, which occurred 
not long since. He has a disturbance above or below the ten- 
torium. From the symptoms which are present it very evidently 
lies beneath the tentorium, in the region of the cerebellum, and 
apparently involving the worm, producing pressure attacks upon 
the floor of the fourth ventricle. The pressure on the fourth 
ventricle being indicated by the respiratory attack, with the 
associated vomiting, and the disturbances of the sixth nerve 
and the hypoglossal nerve on the left side all point to the pos- 



8l2 CLINICS OF JOHN B. MURPHY 

tenor fossa, especially when associated with the cerebellar gait 
and the tendency to pitch forward. The disturbance of his 
hypoglossal nerve might be due either to a disturbance of its 
nucleus, caused by the downward pressure from above, or the 
hypoglossal nerve might be injured somewhere in its course, 
particularly where it passes through the anterior condyloid 
foramen. 

Furthermore, slight value may perhaps be paid to the localiza- 
tion of the man's trouble as he himself figures it out. He believes 
thoroughly that his disturbance lies in the back of his head ; he 
has felt at times sensations of aching and pressure in the back of 
his head. He says that the front and sides of his head are all 
right, but that the back of his head does not seem as though it 
were all right. I think we as diagnosticians should pay a good 
deal of attention to the statements made by the patients as to the 
p)ossible localization of trouble. The old tendency seemed to be 
for physicians to assume that they knew it all and that the pa- 
tient did not know anything. As a matter of fact, a great deal 
that we know about diagnosis has been taught to us by our 
patients. 

The patient has seen many physicians, some of them able 
neurologists in this city. There has been a tendency on the part 
of some to regard the tumor as being situated farther forward 
in the midline. One locaKzation has placed the tumor at the 
junction of the pons and midbrain in the region of the posterior 
corpora quadrigemina. This localization does not seem very 
plausible, although such a localization can easily account for the 
cerebellar gait and the tendency to pitch forward on account of 
the possible involvement of the superior cerebellar peduncles. 
The chief argument against this localization seems to me to be 
the absence of trouble with his fourth cranial, nerve, which would 
almost inevitably sufifer in a lesion at the junction of pons and 
midbrain. Furthermore, after the diagnosis of tumor of the 
posterior corpora quadrigemina had been made, the patient had 
this attack of respiratory difficulty, associated with vomiting, 
indicating irritation of the floor of the fourth ventricle. I would 
place the tumor also in the midline, but farther back than the 



CEREBELLAR TUMOR. — SUBOCCIPITAL COMPRESSION 813 

junction of the superior cerebellar peduncle with the midbrain, 
which is the region of the corpora quadrigemina posterior. I 
am more incHned to believe that it lies in the cerebellar worm. 
In such a locality it can easily compress the floor of the fourth 
ventricle, without producing closure of the foramen of Magendie, 
and without affecting the underlying pyramidal tracts or fibers 
of the fillet. 

This patient sent a description of his symptoms to Dr. Harvey 
Gushing, who sent back a reply to the effect that he regarded the 
tumor as being farther back than the posterior quadrigeminal 
bodies. I did not learn this fact until we had gone over the 
patient's case, because he is rather shrewd and wished to get me 
pinned down to my diagnosis before he told me of another that 
had been made. Dr. Gushing writes: 

"If your diagnosis is correct that this tumor involves the cor- 
pora quadrigemina, I doubt very much if it is capable of removal. 
The symptoms which you give do not make it at all clear that the 
growth is not a simple cerebellar tumor, because the oculomotor 
difficulties are common enough from sub tentorial tumors." 

This was the conclusion which we had arrived at indepen- 
dently of this letter. We believed the disturbance was in the cere- 
bellar region; that it is more apt to be a midline tumor than a 
hemisphere tumor. Gushing writes to the effect that ocular 
disturbances are not uncommon in cerebellar lesions, and that 
they have positively no localizing value. Why? There is an 
important fasciculus known as the posterior longitudinal bundle, 
which passes forward from the medulla and is connected up with 
the nuclei of the seventh, sixth, fourth, and third nerves. It 
frequently happens that when this posterior longitudinal fasci- 
culus is affected by disturbances in the posterior fossa, there 
are also associated disturbances in the third, fourth, and sixth 
nerves. Another explanation for oculomotor involvement is 
that tumors of the posterior fossa produce sufficient distortions 
by pressure to cause oculomotor symptoms. Third-nerve symp- 
toms have no localizing value except when they are intimately 
associated with other symptoms. Third-nerve sjmiptoms are 



8l4 CLINICS OF JOHN B. MURPHY 

to be looked upon as general symptoms of cerebral tumors rather 
than as localizing symptoms. Third-nerve symptoms are, there- 
fore, to be correlated with the general signs of headache, nausea 
and vomiting, and choked disc. 

We conclude that this patient is afficted with a cerebral neo- 
plasm which is located in the posterior fossa; that it is probably 
a cerebellar tumor lying in the midline, involving the worm and 
the fourth ventricle; that it presses downward, and that there are 
irritative phenomena due to pressure upon the floor of the fourth 
ventricle; that the foramen of Magendie is not closed. As to 
the nature of this tumor, we do not believe it to be luetic. The 
man has an absolutely negative history. Wassermann tests, 
both of the blood and cerebrospinal fluid, have been entirely 
negative. The cytodiagnosis of the cerebrospinal fluid was also 
negative. 

[Incision in scalp. Osteoplastic flap outlined downward to 
level of foramen magnum. Hemostasis. Skull opened with 
the Neff trephine. Bone-flap chiseled at the base, broken across, 
and turned back, attached to the flap of Galea. Rongeur forceps 
used to enlarge the opening downward.] 

Dr. Murphy: We have now removed the bone down to the 
foramen magnum, and have the dura widely exposed. I made a 
cupid-bow incision in the scalp clear across the occiput, so as to 
expose the entire cerebellar area and be able to make an extensive 
decompression. I am separating the dura carefully from the 
bone, in order to see clearly what I am doing and to prevent 
premature opening of either the longitudinal or lateral sinus. 
If you open the sinus early in the operation and unexpectedly, 
you are apt to have a very disagreeable hemorrhage. We have 
the dura over the left lobe of the cerebellum well exposed now. 
I cannot detect anything abnormal here, either on inspection or on 
palpation. [Exposes the dura over the right cerebellar hemi- 
sphere similarly, making the excision here a little high to avoid 
a large dural vein which otherwise might have been in the way 
of injury.] We have a complete exposure now of the dura over 
both lobes of the cerebellum. I can see no change on the surface 
of the cerebellum, nor can I feel any difference in the resistance 



CEREBELLAR TUMOR. — SUBOCCEPITAL COMPRESSION 815 

over either of the two lobes on palpation. I do not feel anything 
enough like a tumor to warrant cutting down on it. 

The best thing to stop hemorrhage from the diploe in cranial 
surgery is the Horsley wax. You have just seen an example of 
the efficient work it does in stopping bone bleeding. Now that I 
have a wide exposure of the dura over both hemispheres, I think 
there would not be any advantage in opening the dura. Through 
the opening I have made I could remove a tumor as large as my 
fist if I were only able to locate it; but there is no palpable tumor 
present. We did nick the dura there in one place, and saw the 
cerebellar tissue bulge into the opening. I beheve that to open 
the dura would increase the immediate hazard to the patient. 
Since the tumor is not within reach, a decompression is the best 
help we can expect to give him. 

Let the record show that we made a complete transverse 
removal of the bone over both lobes of the cerebellum down to the 
posterior margin of the foramen magnum and the lateral sinus 
on both sides; that there was no pulsation of the dura and that 
we did not open it. 

I believe that our procedure here was correct. The decom- 
pression will give the patient a chance to develop more localizing 
S)niiptoms. The prognosis otherwise remains unchanged. We 
shall start on sodium cacodylate, 3 grains three times a week, in 
the hope of retarding the development of this tumor, since we 
know that the drug has a retarding effect on certain types of 
malignant neoplasms, particularly those of mesoblastic origin. 
Arsenic can be given in this form in colossal doses without causing 
the patient any toxic symptoms. 

[Note. — The woimd healed by complete primary union. 
There was no particular change in his condition until two weeks 
after the operation, when he began to improve. This improve- 
ment has been gradual but continuous up to the time when he 
left the hospital, July 2, 19 14. — Ed.] 



CONGENITAL LUXATION OF THE PATELLA.— 
REDUCTION.— EXCAVATION OF A GROOVE 
IN THE FEMUR FOR ITS LODGMENT.— 
PLASTIC OPERATION AND IMBRICATION 
OF JOINT CAPSULE TO HOLD IT IN ITS 
NEW POSITION 



I 



HISTORY 

The patient, a boy aged seven, entered the hospital in Oc- 
tober, 19 13, because of a congenital deformity of both knees. 
This trouble was first noticed by his parents following a severe 
attack of measles when the boy was three years of age. They 
noticed then that the child's legs seemed weak and they had to 
teach him to walk again. They paid no more attention to the 
difficulty until September, 191 2, when it was noticed that the 
child was faUing more than usual, especially after nmning. He 
could run well, but when he attempted to stop abruptly he would 
fall on his knees. The parents then noticed that, when the child 
was standing, his knees would touch when his feet were still about 
eight inches apart. He was taken to a doctor, who had braces 
made for him which began at the ankles and were fastened around 
the waist-line. These have helped him considerably to avoid 
falling, but still he falls occasionally. He has worn these braces 
up to the present time. His knees have never been painful or 
swollen, so far as his parents know. 

He was a normal, full-term baby; presentation was by the 
head, and no forceps were used. He began to walk when eleven 
months old, but had to releam walking after his attack of measles 
at three years of age. No other member of the family has trouble 
of this kind. 

VOL. 111—52 817 



8l8 CUNICS OF JOHN B. MURPHY 

COMMENTS AND OPERATION 

Dr. Murphy (October 13, 1913) : From that history you can- 
not make a diagnosis. It has practically no value at all in aiding 
one in the diagnosis. It merely indicates that the child appar- 
ently could run all right, but that when he stopped he went down 
on his knees. There was no trouble getting him to run, but, like 
Frankenstein, the difficulty came in getting him to stop. That is 
the proposition we have to meet here — how to keep him from 
falling when he stops. He is, apparently, markedly knock-kneed. 
That is what his parents noticed and why he was brought here; 
but it is not a typical genu valgmn. I have never seen a case of 
this kind before. The diagnosis is not difficult, however, when 
you stop to analyze the case. When you look at the knee you 
note its flatness on its anterior surface, both in flexion and ex- 
tension. It looks almost like the knee of the patient whose 
patella I took out. If you next palpate it carefully, you will dis- 
cover that there is no patella on the anterior surface of the knee. 
Where is it? It lies on the lateral side of each knee. The inser- 
tion of the quadriceps extensor into the patella, therefore, also 
lies on the external (lateral) surface of each knee. That ana- 
tomic fact explains this remarkable symptom of his, his inability 
to stop suddenly without falling, and also the apparent genu 
valgum. When lying on his back, he can lift the leg if not inter- 
fered with; but if you put slight pressure on the ankle, he cannot 
lift the leg. In endeavoring to lift the leg you saw the line of 
elevation produced on the outer side of the knee-joint, due to the 
quadriceps extensor and the patella under tension. We have seen 
acquired luxations of the patella before, but we have never seen a 
case of congenital luxation — and that a bilateral luxation — until 
now. 

The luxations of the patella of the acquired variety are al- 
most uniformly of the external type. If you examine the lower 
end of such a femur, you will see why. You will note that the 
patella comes well over toward the outer side of the femur, 
and that the supracondyloid ridge in these cases is only very 
slightly elevated. If you let these patients with acquired luxa- 




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CONGENITAL LUXATION OF THE PATELLA 82 1 

tions of the patella lie down, bring them close to the edge of the 
table, distract their attention while you keep drawing the 
leg to the edge of the table, put the thumb on the inner side 
of the patella, and then suddenly drop the leg off the table, the 
patient will scream out, "There it is!" The quadriceps, acting 
like a bow-string, pulls the patella backward along the straight 
outer side of the bent knee with considerable force, and when 
the knee is again straightened, the patella tends to remain in. its 
new position. On the other hand, when the patella is dislocated 
inward, the sloping inner surface of the femur keeps the patella 
from being displaced far backward and tends to return it to its 
normal position when the knee is again straightened. The clini 
cal history of the luxations of the semilunar cartilages is very 
similar to the history of the cases of acquired luxation of the 
patella. The history, in fact, is so nearly the same that all of 
the cases which have been referred to us so far came with the 
diagnosis of dislocated semilimar cartilages. The differential 
diagnosis must be made by the physical findings, the absence of 
tenderness over the semilunar cartilage, the abnormal mobility 
of the patella, and the easy reproduction of the deformity arti- 
ficially. 

[Anterior median longitudinal incision.] 

Now you see the quadriceps tendon and the patella away down 
here to the outer side of the knee. The disagreeable part of the 
operation is going to be the production of a sufficient groove on 
the front of the femur to retain the patella in position here. A 
subpatellar bursa has developed on the outer side of the knee. 
There is the tibial tubercle. You will see this patella lies well 
down on the outer side of the knee. The operation which has 
been most used for the retention in proper position of a patella 
habitually luxated is the one published by Kocher.* In the 
Kocher operation the internal portion of the aponeurosis of the 
quadriceps is carried over the patella to its outer side, and the 
patella thereby displaced inward. That is not the operation 
which we have used in the past, nor the one which we intend to 
follow here. 

* Chirurgiscke Operationslehre, fifth edition, 1907, p. 436. 



822 CLINICS OF JOHN B. MURPHY 

First I shall expose the quadriceps aponeurosis, which extends 
downward and is j&rmly attached to the tibia. The elongated 
vastus intemus has been the chief disturbing element, as it per- 
mits the patella to pass outward. A bursa has developed for 
the patella on the outer side of the femur. I am dividing the 
quadriceps aponeurosis longitudinally on the inner side of the 
patella, thus making a flap which will subsequently be sutured 
over the patella. In order to free this flap we are splitting the 
aponeurosis again about two inches to the inner side of the former 
incision. In dissecting out the aponeurosis I am keeping outside 
of the synovial membrane and exposing only its outer surface. 
In the acquired variety of luxarion of the knee the dissecting out 
of the aponeurotic flap is entirely extra-articular, and the synovial 
membrane remains intact. Here we cannot make our operation 
a completely extra-articular performance because we are com- 
pelled to open the joint in order to make a grooved bed for the 
replanted patella on the anterior surface of the femur, between the 
epicondyles. We are now displacing and overlapping the edges 
of the cut capsule of the joint, just as is done in the imbrication 
operation for hernia, thus adding still more to the strength of the 
structures holding the patella in its new position. 

In tying these sutures we are careful to draw them tightly, 
thus obUterating all the dead spaces and preventing the develop- 
ment of a blood-clot, which is one of the most annoying complica- 
tions with which one has to deal after an operation of this kind. 

Let the record show that the patella was found as we pictured 
it, on the external surface of the external condyle of the femur, 
as indicated both by physical examination and the ic-ray; that 
the capsule was freed and the joint opened; that the patella was 
freed from its external attachments so that it could be displaced 
inward and the vastus externus, its aponeurosis, and the fibrous 
capsule of the joint divided longitudinally for a distance of four 
inches; the vastus intemus, its aponeurosis, and the fibrous joint 
capsule were likewise divided longitudinally and freed clear to 
the tip of the internal condyle, thus making an overlapping flap 
for imbrication; that a supracondyloid groove was made with 
the chisel on the anterior surface of the femur and that this bony 




Fig. 249.— Showing luxated patella on outside of knee, with line of initial incision. 



823 




Fig. 250. — Showing luxated patella on outer surface of knee-joint. Lines of division of 

capsule for freeing it. 



8i4 




ig. 251. — Preparation of new groove for patella on anterior surface of the femur. 



825 





k^ 



Fig. 252. — Ariilaial palcUa ^unnv ami pedicle fascia and fat flap pu,- 

covering same. 



826 




Fig. 253. — Interposing flap in position. 



827 




Fig. 254.— Method of secuririK patella to uiuitr Mui.m 01 nhrous cai)sule. 



828 




Fig. 255. — Internal capsular flap overlapping the patella to prevent recurrence of 

luxation. 



829 



I 



CONGENITAL LUXATION OF THE PATELLA 83 1 

defect was covered with a portion of the subquadriceps bursa 
before placing the patella in it; that the outer portion of the 
vastus internus muscle was passed over the patella and sewed 
to the divided capsule at its external margin; that the inser- 
tion of the tendo patellae was displaced inward and fixed to the 
normal tubercle of the tibia, whereas previously the insertion 
was on the external surface of the tibial tubercle; that the joint 
was then closed, and the capsule and soft tissues sutured; that 
there was some bleeding during the operation, which rather 
rapidly subsided, so that at the completion of the operation there 
was no bleeding, and we did not have to put on a single ligature; 
that the imbrication flaps were made so as to secure the patella 
against a possible relapse to its former position. 

SUBSEQUENT HISTORY 
The patient reentered the hospital on May 5, 1914. His 
parents state that since the operation on the right knee the boy 
falls less frequently than formerly, and the right knee does not 
turn in in genu valgum as it did prior to the operation, and as 
the left one does yet, nor does the right knee any more give way. 
He still occasionally falls when trying to stop quickly while 
running, or when attempting to turn suddenly, because of the 
luxation still existing in his left knee. Since the operation he 
has been in perfect health. 

COMMENTS AND OPERATION 
Dr. Murphy (May 6, 1914): The only real difficulty this 
child had was that while he can run as fast as the other boys of 
his age, he cannot stop abruptly without falling on his knees; 
and that is the t3^ical symptom of this condition. He was born 
with complete external luxation of both of his patellae. The 
left patella rests entirely on the outer side of the knee-joint. 
That is why, when he stops, his knees shoot out in front of him 
and he falls. When he is lying on his back he cannot lift his left 
leg up straight. When you look at him you will notice that there 
is a deformity at the knee. A layman will not observe it, and a 
doctor has to be looking for something there in order to find it. 



832 CLINICS OF JOHN B. MURPHY 

We have operated on the right leg for the same deformity. I 
will ask the doctor to read the report of the previous operation. 

[Intern reads report.] 

Dr. Murphy : I divided the vastus intemus muscle, detached 
it from the inner side of the patella, brought it clear over the 
patella, and attached it to the outer margin of the patella to hold 
the patella in its new position, because otherwise the luxation 
might recur. You remember the operation I performed the other 
day for an acquired unilateral luxation of the patella. This was 
about the same type of operation except that here the degree of 
deformity is greater than in the acquired luxation. 

You cannot outKne the patella by inspection on either knee 
because the patellae are not yet sufficiently developed to produce 
a visible prominence. Neither patella has had much of any 
use, and, therefore, neither has grown as a patella should grow. 
The left patella rests on the outer side of the knee in the same 
position as did the right before we operated it. In place of an 
intercondyloid depression on the front of the left femur, there 
is an intercondyloid elevation, because there has never been a 
patella there to produce the depression. Unless this inter- 
condyloid elevation is removed and a groove made to receive 
the patella, the latter will not remain in its new position, but 
will relapse to its former condition of external luxation. 

At the preceding operation, after I had opened the joint 
and exposed the lower end of the femur, I chiseled out a groove 
on the anterior surface of the femur between the epicondyles, 
about lyi or three inches in length, to make a depression to re- 
ceive the patella and to help maintain it in its new and proper 
position in front of the knee. The raw surface of the femur was 
then covered by the subquadriceps bursa in order to provide 
a new articular surface for the patella to glide over — ^very much 
the same procedure which we follow in performing an arthro- 
plasty on the knee. This plan produced about as perfect a 
limb as one could find. The boy has full control of it and can do 
anything with his operated leg that any boy can do. The opera- 
tion was a complete success. We hope to get as good a result with 
this left knee as we did with the right. 




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VOL. m— 53 



833 



CONGENITAL LUXATION OF THE PATELLA 835 

We had in the hospital this week another case of luxation of 
both patellae — acquired, not congenital, like this case; con- 
tinuous, not a recurrent affair, as many of these acquired luxa- 
tions are, and an internal, not an external, luxation. I think 
we have now seen about 12 of these luxations of the patella. 
This other patient developed his luxation as the result of an in- 
fection. During the infection his knees were permitted to flex 
and his patellae slipped over the supracondyloid ridge to the 
inner side of the joint. He walks in a semi-erect position with 
a cane, very much as you have seen boys walk squatting around 
a pole when playing Indian and imitating the war-dance. The 
patient's legs are greatly flexed, but he cannot quite simunon 
up the courage to be operated on. He is a man, and men have 
not the capacity to endure pain which many women have. If 
he had been a woman, he would have been operated rather than 
have continued to live with this unsightly deformity. He was 
a man, and a doctor's brother, and yet he demanded a guarantee 
of a perfect result before he would consent to operation. If he 
wants perfect locomotion guaranteed, he should spend his money 
on an automobile. We are not in the guaranty business, and 
the patient is not now in the hospital. When his courage and 
common-sense increase he will probably return. A good result 
is more certain with this boy, because his legs are still straight. 
The difficulty with this other patient would have been to keep 
the legs straight after once getting them properly extended. We 
would have had to elongate both the internal and the external 
hamstring muscles in his case. Not only might there have been 
difficulty in straightening the limbs, but in straightening them 
a paralysis of the external popliteal nerve might have resulted 
from the stretching of the bent Hmbs, as is a common occurrence 
in these flexion deformities. Then the patient has a drop-foot 
for a time, although function usually returns all right ultimately, 
just as does the compression paralysis of the external popliteal 
nerve from a bandage too tightly applied. 

[Anterior median incision through skin, fascia, and muscle, 
just as in the preceding operation. Synovial membrane incised 
and joint cavity exposed.] 



836 CLINICS OF JOHN B. MURPHY 

There is the patella. I am sliding it under my finger. There 
is the elevation on the anterior surface of the femur between 
the two condyles, which I must remove in order to make a bed 
for the patella. There is also some external rotation of the tibia 
present. 

We have applied a constrictor to this limb because we want 
a dry field in which to work, and want to keep blood out of the 
joint. Before making the groove on the anterior surface of the 
femur, I must elevate the synovial membrane and the periosteum 
covering the femur, because I shall bring these structures back 
to make a covering for the denuded bone, so that the patella 
will not become agglutinated to it. In the right knee I used 
also the subquadriceps bursa to make a new articular surface 
beneath the patella, much as we do in a knee arthroplasty. In 
chiseling out the intercondyloid depression the highest elevation 
must be made on the outer side, since the tendency is great in 
these cases for the luxation to recur on the outer side of the joint. 
I wish nature would be kind enough in all oiu: arthroplasties 
to give us as good a material for arthroplastic work as we have 
in this knee. It would make us very happy, and make these 
operations much more agreeable undertakings for the surgeon. 

Let the record show that we took the external portion of the 
fatty capsule of the joint and spread it over the groove in the 
femur made by the curved chisel. 

I am making the imbrication by passing the inner flap of 
aponeurosis over the outer flap, covering over all of the patella, 
and am also using an overlapping flap of the vastus intemus. 
Thus we have the flaps well secured and we divide the aponeurosis 
of the vastus intemus a little farther up on the outer side, so as 
to free the patella still more from any tendency to relapse to 
its former position. 

Let the record show that there was a complete external luxa- 
tion of the patella; that a median anterior skin incision was 
made; that first the capsule was divided on the outer side of the 
patella, the knee-joint opened, and the outer side of the patella 
freed of ligamentous attachments; that then the vastus internus 
and the internal portion of the capsule were separated from the 



CONGENITAL LUXATION OF THE PATELLA 837 

quadriceps tendon and from the patella and a large internal flap 
prepared; that an intercondyloid groove was prepared on the 
femur to receive the patella, after first elevating the synovial 
membrane and a portion of the capsule, which were to be utiKzed 
to cover the raw surface of the bone at the completion of the 
chiseling out of the intercondyloid groove, in order to prevent 
the patella from coming into contact with the freshened surface 
of the bone; that the patella was then freed and the vastus 
externus divided longitudinally for a distance of six inches; 
that the outer portion of the quadriceps tendon was also di- 
vided and rolled inward so as to prevent traction on the patella 
in the future in an outward direction; that we made an imbri- 
cation flap of the internal portion of the capsule and the vastus 
intemus, carrying the inner margin of the patella and the quadri- 
ceps tendon imder the vastus internus for a distance of i^ inches 
and then overlapping the patella fully with the vastus internus, 
which was united clear over to the outer margin of the patella, 
so that there is muscular contraction, all of the time, pulling the 
patella inward. 

I detached the vastus externus from its external attachment 
because this muscle tends to pull the patella outward, and getting 
rid of this external pull is one of the things which insures a 
permanent result. 

I will show you this other leg, which we operated last Oc- 
tober. There is perfect conformation of the knee with the 
patella in perfect position in the groove in the femur. The 
patient has normal flexion and extension at the knee, and the knee 
furnishes normal support. The patella cannot escape from that 
groove, because it has been firmly secured in position by our 
imbrication operation. The groove for the patella in the right 
femur was chiseled out just as we chiseled out the groove in the 
left femur this morning. The right patella is still very small, 
but it will attain its full size in time, with use, I believe. Re- 
member that the presence of the patella is not at all necessary 
for the full usefulness of the limb. We have had a nimiber of 
cases of tuberculosis of the patella alone, in which we have re- 
moved the patella completely, and yet had perfect joint fimction 



838 CLINICS OF JOHN B. MURPHY 

preserved. In performing this operation we split the quadriceps 
in the middle, stretch apart the two halves, enucleate the patella 
completely, and curet away any tuberculous material or granula- 
tion tissue which may lie outside of it. We then unite the quadri- 
ceps tendon to the tendo patellae over the operative defect, 
elongating it as much as may be necessary to bridge over the 
space. We have had beautiful results following this operation 
and the patients can not tell from any difference in the fimctional 
capacity of the knee that the patella had been taken out. They 
can all walk perfectly and pursue the same activities as if they 
had a normal patella over the knee. The question is active in 
my mind as to whether I shall not remove the patella regularly 
in my arthroplasty operations on the knee and elongate the quad- 
riceps tendon. However, if the patient has an ankylosis at an 
angle and enough bone is removed to make the limb straight, 
one may then perform the operative procedure which I have 
been using, turning the patella turtle and sewing it back in place 
in that reversed position. In none of these patients has the 
patella become gangrenous. A little necrosis occurred on the 
edge of one patella, but healing finally ensued without any 
sequestnun formation. By turning over the patella one is 
certain to prevent subsequent ankylosis, because the supra- 
patellar bursa makes the finest kind of a lining for the new joint. 

This Umb will be dressed in a simple Buck's extension after 
the iodin on the leg is neutralized. If the wound remains 
sterile, — and we believe it will, — the patient should have a perfect 
functional result, just as good as in the other limb, and that is 
perfect. 

[Note. — Complete primary healing of the wound. The pa- 
tient was up at the end of two and a half weeks. He left the 
hospital May 29, 1914, still walking about on crutches, but 
already able to use the knee with very little discomfort. — Ed.] 



RECURRENT LUXATION OF LEFT PATELLA. 
—INTERNAL IMBRICATING FLAP OPERA- 
TION.— PARALYSIS OF RIGHT LEG, WITH 
A FLAIL-JOINT AT THE ANKLE.— ARTHRO- 
DESIS 



HISTORY 

The patient, a seventeen-year-old girl, entered the hospital 
in April, 1914, with the following history: 

She walked when one year old, and appeared normal in every 
way. At eighteen months of age she was taken ill with chills 
and ran a high fever, which lasted about three weeks. The doc- 
tor who attended her said she had meningitis. She was confined 
to bed for two months. Following this illness the entire right 
half of her body was paralyzed and numb, the arm and leg both 
hanging limp. During the next four months the arm and trunk 
gradually recovered both motion and feeling, but the lower limb 
from the hip to the foot recovered much more slowly than the 
upper limb, and it was not until eight months after the illness 
that sensation and some motion returned. 

She can now abduct, adduct, and rotate her right thigh freely. 
Her right foot hangs limp. With the aid of a leg-brace she can 
walk, but she cannot bear much weight on the right leg. 

In November, 1913, while walking to school, her left knee 
suddenly turned in and she fell. She could not rise. She was 
taken home and kept in bed about one month. The family doctor 
said she had a floating cartilage. He ordered a leather brace 
made, which helped her to walk. Three days after getting up 
from this illness the knee turned in once more while walking, and 
she fell again. Her knee became swollen and painful immediately 
after the accident, and she remained in bed another month. 
She returned to school and had no more trouble until March 20, 
1914, when, while standing still, her weight resting entirely on 

839 



840 CLINICS OF JOHN B. MimPHY 

her left leg, on account of the right being crippled, the left knee 
again gave way and the knee-cap slipped to the outer side of the 
knee, as it had done twice previously. The knee became swollen 
and painful. The patient has not been able to walk since March 
20, 1914. 

The patella of the left knee is freely movable on the femur, 
and there is a little soft crepitus underneath it. The right hip, 
thigh, and leg are smaller than the left. The left knee can be 
moved in all normal directions. The left knee has never locked 
at any time. It merely gives way beneath her. 

IMBRICATING FLAP OPERATION ON LEFT KNEE.— COMMENTS 

Dr. Murphy (April 29, 1914) : The patient suffered a paraly- 
sis of both the lower and upper right extremities following an 
anterior poliomyelitis either with or without an encephalitis. It 
was more than an anterior poliomyelitis, was it? 

Intern: Her doctor said she had a meningitis. 

Dr. Murphy: Yes, there must have been an upper neuron 
lesion as well as a lower because of the very considerable range of 
muscular involvement. With only a leg-brace she walks on the 
leg easily without the aid of cane or crutch, a remarkably good 
recovery for such a severe lesion as the history indicates. What is 
the matter with her? 

Intern : I suppose she has a luxation of the patella. 

Dr. Mxjrphy: What makes you think so? 

Intern: Because she fell to the ground suddenly each time. 

Dr. Murphy: Yes, but she would fall to the ground just as 
suddenly if she had a luxated semilunar cartilage. 

Intern: But her knee never locks and the patella has slipped 
clear around on the outer side of the knee. 

Dr. Murphy: No, it is not around on the side of the knee. 

Intern: It can be pulled around there, and there is crepitus 
present in the joint. 

Dr. Murphy: But there is also crepitus with a synovitis 
and with a dislocated semilunar cartilage. Crepitus occurs in 
the knee with many lesions. What is there in the history which 
makes you think she has a luxation of the patella? 




Fig. 258. — Recurrent external luxation of left patella. The a;-ray shows an 
apparently perfectly normal knee, and furnishes only negative evidence for the 
diagnostician. The diagnosis must be made from the history and physical examina- 
tion as outlined in the text. Radiogram before operation. Anteroposterior view. 



841 




Fig. 259. — Recurrent external luxation of left patella. Note the apparently 
normal knee-joint, no sign of an external luxation being apparent, because the 
luxation spontaneously reduces itself after each recurrence. Radiogram before 
operation. Lateral view. 



842 



RECURRENT LUXATION OF LEFT PATELLA 843 

Intern: She cannot bear any weight on the knee. 

Dr. Murphy: Why? 

Intern: Because the knee turns in. 

Dr. Murphy: No. She can put her whole weight on it if 
she stands straight. What makes you think she had a luxation 
of the patella at all? Because she told you so? 

Intern: She did not tell me anything. 

Dr. Murphy: If she didn't tell you anything, where did you 
get all this history, doctor? 

Intern: I asked her what happened to her, and she replied 
that when she was walking along the street the knee turned in. 

Dr. Murphy: Why did you suppose it was the patella at all 
which was involved? What makes you think she had a luxation 
of the patella? It is a very rare lesion. 

Intern: I do not know any further diagnostic points. 

Dr. Murphy: Was her patella ever pulled on to the outside 
of the knee by the accident? 

Intern: The doctor said so. 

Dr. Murphy: No. That statement is misleading. The 
doctor did not have to pull it back into place. After the first 
time that this occurred the patient picked herself up and walked 
three blocks to school. She could not walk three blocks to the 
school-building with her patella on the outer side of the knee. 
She walked with the assistance of a girl friend, it is true, but the 
patellar luxation reduced itself. She did not have to pull the 
patella back from the outer side of the knee. That is the regular 
story in this condition. I remember the first luxation of the 
patella which I had to treat. The patient was the wife of a 
United States army officer on duty at Buffalo. She went all 
over the world trying to find out what was the matter with her 
knee, and to get relief for it. It was diagnosed repeatedly as a 
dislocated semilunar cartilage. I had her lying close to the side 
of the examining table when the excessive mobility of the pateDa 
first attracted my attention. A patella which has been repeat- 
edly luxated becomes so excessively mobile that, with the leg 
extended, the patella can be pulled outward over the external 
supracondyloid ridge and out of the intercondyloid groove. 



844 CLINICS OF JOHN B. MURPHY 

There is a supracondyloid ridge on both sides of the patellar 
groove in the femur. The patella seems never to slip over the 
internal ridge. At least, I have never seen a recurrent internal 
luxation. The patella in these cases catches on the upper end of 
the external ridge as knee flexion begins, and, in place of coming on 
the inner side of the ridge into the patellar groove, as it should, 
it comes down on the external supracondyloid ridge and then turns 
over it on to the outside of the joint. As I was talking to her I 
kept working the leg a little closer to the side of the table, hooked 
my finger on the patella, pulling it outward, and then suddenly 
slipped the leg off the table. The patella slipped out with a snap 
and the patient screamed, "There it is!" I had the patella clear 
out on the lateral surface of the knee, so that I could demon- 
strate it to any one's satisfaction. I shall try and demonstrate 
the luxation of this girl's patella when we get her asleep. If one 
tries to bring the patella over to the outside of the knee with the 
limb flexed, one cannot do it; but if one starts it above the supra- 
condyloid ridge, as I did, it can usually be done easily. I have 
brought out these points purposely because the doctor's history 
does not fit the facts. This girl's patella was never seen outside 
the knee, and was never felt outside. Each time when she came 
to look at it, the leg had straightened and the patella was back 
in position. Such a knee does not lock as does a knee with a 
semilunar cartilage dislocated. Many of these cases of luxation 
of the patella are operated for semilunar cartilage luxations, and 
the result, naturally, is that they are not cured. 

[Dr. Murphy dislocates the patient's patella by the manipu- 
lation outlined above.] 

There is the patella on the outer side of the knee. As soon 
as she relaxed I had no trouble bringing it on the outer side. 
The patella always starts to slip out above at the upper border 
of the groove. That is where we must pay particular attention, 
therefore, in our treatment. We have devised a special opera- 
tion which has worked admirably in these cases. We shorten 
the attachments of the patella to the inner side of the knee, so 
that the patella cannot slip over on to the external ridge. 



RECURRENT LUXATION OF LEFT PATELLA 845 

Ail this work must be done without even the gloved hand con- 
tacting with the wound. 

[External (lateral) longitudinal incision. Exposure of the 
quadriceps.] 

The field of operation must be perfectly dry to recognize the 
quadriceps aponeurosis, which it is especially difficult to identify 
in these fat women. There above lies the aponeurosis of the 
vastus internus. That is a guide to this work. The patellar 
groove is very narrow in this patient; in fact, we have practically 
no depression on the anterior surface of the femur, certainly a 
predisposing factor in this luxation. I must cut through the 
quadriceps aponeurosis and the fibrous capsule of the joint. See 
how carefully I am picking up the fibrous capsule and dividing 
it, because I do not wish to open the synovial membrane of the 
joint, and shall thus avoid any possibility of an articular infection. 

Next I separate the fibers of the vastus internus muscle and 
of the fibrous capsule on the inner side of the joint, and come into 
the zone of loose areolar tissue between the synovial membrane 
and the fibrous capsule. I am endeavoring to prepare two im- 
bricating flaps of all the structures outside of the synovial mem- 
brane without puncturing or wounding the membrane itself. 
Here is where the capsule separates. This zone jusf outside 
the synovial membrane is the location where the metastatic ar- 
thritides occur. They occur in this zone of loose areolar tissue 
and later break from here into the joint. 

[Continues with the dissecting back of the flaps.] 

Now I have prepared one flap successfully without opening 
the joint. This shortening of the internal attachment of the 
patella by the formation of imbricating flaps is the most important 
part of the operation, because if we can prevent the patella from 
starting down the external supracondyloid ridge, we can prevent 
the recurrence of luxation. The flaps here are made of fascia 
and placed overlapping each other very much like the imbricat- 
ing flaps in Andrews' operation for the cure of inguinal hernia. 
There is a little fat on the surface of the flaps which I must wipe 
off, because the fat lies where the flaps are going to come into 
contact with each other, and would interfere with their union. 



846 CLINICS OF JOHN B. MURPHY 

We shall commence the imbrication at the upper portion of 
the wound. Here is where the chief support must be given. I 
am overlapping the aponeurosis of the vastus intemus. The 
catgut with which I am suturing the flaps is not allowed to con- 
tact in any way with the gloved hands. It is handled and tied 
entirely with instruments. 

[Imbrication of the internal flaps finished.] 

Next we shall divide longitudinally the aponeurosis of the 
vastus extemus and lap the inner portion of it over the patella 
and imite it with the imbricating internal flaps. We shall divide 
the outer portion of the fibrous capsule of the joint longitudinally 
down to the synovial membrane, but not through it, and shall 
roll under the cut edges so that they cannot reimite by scar tissue 
and later tend to draw the patella again to the outer side of the 
knee. 

This is the last of the catgut stitches which fasten these rolled- 
in edges in place. All these operative procedures have been 
carried out entirely outside of the synovial membrane, which is 
still intact at the close of our operation, as we are commencing to 
tie the last deep sutures. In place of having a knee-cap loose in 
all directions, in the future the patient will have a knee-cap lim- 
ited so far as lateral motion is concerned, but still freely movable 
up and down, the only direction in which patellar motion is 
essential to the patient. 

Let the record show that the left patella was very freely mov- 
able, laterally as well as up and down, before the operation; that 
preceding the operation we were able readily to luxate the left 
patella to the outer side of the leg as soon as the patient was 
under the influence of the anesthetic. 

As we did not enter or even puncture the joint cavity, we do 
not intend to put a Buck's extension on the patient, as we do 
commonly when we have opened the knee or any other weight- 
bearing joint. At the end of two weeks we shall have her com- 
mence to walk, the knee supported by a straight splint. We shall 
not permit her to flex the knee imtil four weeks after the opera- 
tion, by which time there will be a complete organic union of the 
imbricating flaps consisting of the fibrous portion of the capsule. 




Fig. 260.— Recurrent luxation of the patella. Skin incision. 



847 




Mg. 261. — Incision through the quadriceps aponeurosis and fibrous capsule oi 

the joint. 



843 




Fig. 262. — Preparation of the imbricating flaps of quadriceps aponeurosis and 
fibrous capsule of the joint. Passing of the mattress sutures. Note that the 
joint jtself is not opened in this operation. The outer surface of the synovial mem- 
brane lies exposed at the bottom of the wound, but is intact. (It was unnecessary 
to open the joint here because there was already a good bed on the anterior surface 
of the femur for the reception of the patella. It is only in the congenital luxation 
cases that a new bed for the patella has to be chiseled out of the anterior surface of 
the femur, thus necessitating the opening of the joint.) 



VOL. Ill — 54 



849 





Fig. 263. — The imbricating flaps are in place, the mattress sutures tied, and 
the continuous approximation sutures finished. 



850 



RECURRENT LUXATION OF LEFT PATELLA 85 1 

Let the record show that the fibrous capsule was opened over 
the entire anterior and lateral surfaces of the joint, beginning at 
the upper angle of the wound on the vastus muscle, because that 
is the easiest place to start the separation of the capsule; that 
the synovial membrane was not opened or even punctured; 
that the patellar portion of the fibrous capsule was elevated from 
the synovial membrane for an extent of one inch; that there was 
only a sHght exposure of the posterior portion of the fibrous 
capsule; that the imbrication operation was then performed, 
burying the posterior half of the fibrous capsule on the inner 
surface of the joint beneath the anterior half for the entire length 
of the capsule; that the vastus muscle was divided on the inner 
side for a distance of two inches and an upper overlapping flap 
made of it so as to fix the upper portion of the quadriceps tendon 
toward the inner side of the joint; that these measures are chiefly 
aimed at preventing the patella from slipping on to or outside of 
the external condyloid ridge at its upper end, and in that way 
preventing a recurrence of the luxation; that the skin was closed 
with horsehair with no supporting silkworm-gut sutures; that 
no extension was applied to the knee after the dressing was put 
on the wound. 

[Note. — The wound healed by complete primary union. 
Movement in the knee appears to be normal as far as one can tell. 
She can flex the knee to a right angle. No pain at any time to 
amount to anything. — Ed.] 

ARTHRODESIS OF ANKLE.— COMMENTS 

[History reread by intern.] 

Dr. Murphy (June 17, 1914) : What can the patient do with 
her right lower Kmb? 

Intern: She can flex the thigh on the body. 

Dr. Murphy: Is that all? 

Intern: The right foot hangs limp and powerless. She 
cannot use it. 

Dr. Murphy: Not at all. That girl can walk without a cane 
or crutch. Could she walk without a cane or crutch if that 
statement of the doctor's were true? Not at all. She has full 



852 CLINICS OF JOHN B. MURPHY 

power of extension of the leg, which means that her quadriceps 
extensor is fully intact. She has full power of contraction of all 
the internal hamstring group, the semitendinosus, the semimem- 
branosus, and the gracilis. She has power of contraction in the 
sartorius, but she has no power of contraction of the biceps fe- 
moris. That means what? That means that she can sit up in a 
chair and stretch her leg out perfectly straight. According to the 
doctor's statements, she cannot extend her leg out straight, but 
can only flex it at the thigh. She can bear her whole weight on 
the leg when it is thrown back, but she cannot control the posi- 
tion of her ankle in walking. It turns inward continually. Her 
leg and knee are all right, but her ankle rotates helplessly. She 
has a complete flaccid paralysis of all the muscles below the 
knee, those suppUed by the external popliteal nerve as well as 
those suppUed by the internal popliteal. She has no available 
muscle or tendon that we can transplant from one side of the leg 
to the other. What I had thought of doing was to shorten or 
transplant the tendon of the tibialis anticus and over the anterior 
portion of tibia, overlapping and suturing it, making a contracture 
of the ankle in flexion; but I came to the conclusion that that 
fixation would not be strong enough and that she would still 
have the ankle turn in and would still walk on the internal 
malleolus, because shortening the tibialis anticus tendon would 
not give even temporary relief of the eversion of the foot. 
Therefore I have been forced to perform an arthrodesis of the 
ankle-joint in order to produce permanent bony ankylosis be- 
tween the astragalus and the tibia to put the foot into a position 
where it will stay without turning during walking. Such a foot 
while not entirely satisfactory from a functional standpoint is 
far more useful and reUable than an artificial foot. 

Only yesterday I had a man at the office with a foot and ankle 
deformity, the external appearance of which was very similar to 
this girl's deformity. His lesion, however, turned out to be a 
luxation of the head of the astragalus inward. I never saw one 
before. The luxation occurred gradually inward and downward 
over the scaphoid, so that the head of the astragalus protrudes as 
a large mass which comes into contact with the ground like an 




Fig. 264.— Complete flaccid paralysis of all muscles below the knee, producing 
a flail-joint at the ankle, for which an arthrodesis, therefore, became necessary. 
Radiogram before operation. Anteroposterior view. 



853 




Fig. 265. — Flail ankle-joinl. Note how slight is the "atrophy of disuse" in 
the bones as compared with the marked atrophy in the paralyzed muscles. Radio- 
gram before operation. Lateral view. 



854 



RECURRENT LUXATION OF LEFT PATELLA 855 

exaggerated flat foot. The luxation was, probably, originally 
the result of an injury; but the injury occurred many years ago, 
and the deformity has been a gradual and relatively recent de- 
velopment. His foot is very lame at present because of the pain 
which the increasing deformity causes in walking, owing, doubt- 
less, to stresses on the ligaments and nerves about the ankle. 

I had hoped when I examined this patient first that I could 
work out some means of turning downward a portion of the quad- 
riceps tendon. If we could thus produce a dorsoflexion of the 
foot, the weight of the foot might be depended on to furnish some 
extension, and we should thus produce a foot which would be 
very useful in walking; but I could not work out the problem of 
producing that length of a transplant from the quadriceps ten- 
don which would have to be inserted into the tibiaUs anticus in 
order to function. If she had either of the anterior or posterior 
tibial groups of muscles preserved or the external or internal 
popHteal groups intact, then we could have produced such a 
result. We could have utilized any one of these groups. But all 
the muscles innervated by the sciatic nerve are out of com- 
mission, and the biceps femoris is also functionless. [Demon- 
strates the patient's leg and foot and then the x-ray plates to 
the clinic] 

There is a httle change in the conformation of the lower 
articular surface of the tibia. The bones about the ankle-joint 
are not fully developed. The articular surface of the fibula, in 
place of standing at a right angle to the articular surface of the 
tibia, Hes at an obtuse angle to the midline of the limb. That 
is the sequence of walking on the deformed ankle. By doing an 
arthrodesis we can produce an ankylosis of the ankle-joint which 
will help greatly to steady the ankle in walking. Some time ago, 
I think it almost a year, we performed an arthrodesis on a Char- 
cot ankle-joint in the endeavor to secure a permanent ankylosis. 
We did not get a bony union, however, and we are going to take 
out tomorrow the remaining nail which we inserted originally to 
hold the denuded articular surfaces in juxtaposition. In that 
case we drove two nails through the sole at the heel into the cal- 
caneus, then through the astragalus and into the shaft of the 



856 CLINICS OF JOHN B. MURPHY 

tibia. We removed one nail afterward and could not extract 
the other after grasping its head with any instrument in our 
armamentarium, but now it has loosened up of its own accord 
so that I think we can get it out. 

Our plan with this girl is to chisel away the articular surfaces 
of the tibia, fibula, and astragalus, removing all the articular 
cartilage from the bones forming the ankle-joint. If, in operating 
on this joint, it happened that we did not want to produce an 
ankylosis, it is highly probable that that is just the result which 
we should get, as we all know to our sorrow; but when we want 
and plan for a complete bony ankylosis, a contrary Providence 
regards it as an entirely different proposition. As dear old 
Professor Allen used to tell us students," Such is the innate cussed- 
ness of the nature of human things/' We expect to get a com- 
plete bony union here just the same. I think that ultimately 
we shall be able to inject these joints with some preparation, 
such as formalin, perhaps, and produce an ankylosis without 
performing a cutting operation. I did not dare to try it in this 
ankle, because its nutrition is so feeble that it would not offer 
enough resistance to the destruction which so powerful an agent 
would produce. The local nutrition has been so interfered with 
by her nerve lesion that we should thus run considerable risk of 
producing a gangrene of the foot. 

One can turn an arthrodesis to service in many places. If 
the patient has lost control, for instance, of a knee, if the exten- 
sors all are completely paralyzed one can make a very serviceable 
limb by producing an ankylosis between the ribia and the femur 
and making the limb stiff but straight. Such a limb is far more 
useful and dependable than an artificial limb or crutches. Such 
an arthrodesis is particularly useful in the anterior poliomyelitis 
cases. The limbs are thus made stiff, but they give good support. 
"A good result" in all these cases is a matter of comparison. 
If this girl can be made to walk without using a support or wear- 
ing a brace, it will be of great advantage to her. 

We demonstrated a patient here recently who had a complete 
paralysis of the quadriceps extensor femoris before we operated 
her. The girl could not walk at all. She had no paralysis. 



RECURRENT LUXATION OF LEFT PATELLA 857 

however, of the posterior group of muscles suppKed by the sciatic 
nerve. We took the tendon of the biceps femoris, detached it 
from its insertion into the head of the fibula, freed the tendon 
backward for a distance of several inches, passed it forward 
underneath the skin and subcutaneous fat, transfixing the quad- 
riceps tendon, and brought the end aroimd and implanted it 
into the quadriceps tendon. With the help of the power of 
extension thus given to the leg the patient learned to walk 
without a cane or crutch. She trained herself to utilize the 
biceps, which [is a flexor muscle, as an extensor muscle. The 
patients learn to control this new function rather rapidly, as a 
rule. After transplanting tendons and nerves in dogs we found 
that the animals when they first started to walk went very 
crooked, but in a few weeks learned to send the impulses over the 
right nerves, and then became able to get about just as though 
nothing had happened, showing how even lower animals are able 
to train themselves to use a new mechanism. If a dog could 
train itself to do that, we figured that a himian being could do 
likewise or better, and get a very good and serviceable limb after 
such a transplantation operation. 0\ir expectations have been 
fully justified by the results we have secured with such patients. 

The use of braces is not a very good proposition from a 
surgical standpoint. It was a very poor surgical proposition, 
indeed, until Mr. Jones, of Liverpool, took up the problem with 
the enormous mental and physical force and vigor so character- 
istic of all his scientific work. Until he worked on this subject 
the results of orthopedic treatment in this class of cases were 
much inferior to what we are obtaining now. He has applied 
the brain and technical accuracy of a great surgeon to orthopedic 
work, and thus at last secured good results in this Hne of treat- 
ment. The clinic of this Liverpool surgeon now has the reputa- 
tion of being the first orthopedic clinic of the world. Undoubt- 
edly Jones does better work and gets better results in this line 
than any man who ever lived. 

We carry out most of this arthrodesis work with the artist's 
chisel, which is a thin steel chisel used by artists for carving. 
On account of its length it lets one work at a greater distance 



858 CLINICS OF JOHN B. MURPHY 

from the bone and allows one a better view of the field of opera- 
tion than any other chisel used for this purpose. 

[Makes a longitudinal incision over the anterior surface of the 
ankle. Exposes the capsule of the joint, opens it, and begins to 
chisel away the articular cartilage from the ends of the bones 
making up the joint.] 

We first chip off the articular surface of the tibia, then the 
articular surface of the astragalus, the articular surface of the in- 
ternal malleolus, and, lastly, the articular surface of the exter- 
nal malleolus. 

Visiting Doctor: What is the age limit for this operation? 

Dr. Murphy: Since these conditions occur practically al- 
ways in young children, we do the operation just as soon as the 
ankle rotation becomes marked. We never cut away the articu- 
lar ends of the bones far enough to encroach on the epiphyseal 
line, and so do not interfere with the subsequent growth of the 
bones. These patients get the same functional result that one 
gets with a metastatic arthritis which terminates in an ankylosis. 

These freshened surfaces will not stay in proper position with- 
out a nail to hold them. I make a nick with the scalpel in the 
skin over the under surface of the heel and then drive in a wire 
nail through the calcaneus and astragalus into the tibia. This 
nail eventually will probably be taken out, but by that time it will 
have served its purpose. We have the foot in good position and 
also have it secure. I reunite and overlap the anterior annular 
ligament, which I had to cut to expose the joint properly. We 
want to get all the strength we can to support and hold this joint 
rigid. 

Let the record show that we were able to expose the ends of 
all the bones very readily; that we took off all the articular 
surface of the astragalus, the tibia, and both of the malleoli; 
that we did all this work without contacting the gloved hands 
with the wound or with the instruments where they had touched 
the hands; that only one nail was inserted and that this was 
driven up through the os calcis and the astragalus into the tibia. 

Let the record also show that we did not permit the nail to 



RECURRENT LUXATION OF LEFT PATELLA 859 

touch the skin of the foot; that we incised the skin with the 
scalpel in order to avoid this contact. 

This operation is not difficult. The incision is made an- 
teriorly in the midline of the ankle, and the anterior tibial artery, 
tendon, and nerve were displaced to the side. In a few strokes 
of the knife one is in the joint. Then elevate the bones from the 
joint and chisel off the articular surfaces. The artist's chisel 
allows one a splendid view of the field during the work. There is 
such a small cutting surface and so narrow a shaft to the chisel 
that one can see around it without difficulty. As much cannot 
be said for many of the chisels with which surgical instrument 
houses provide us. 

[Note. — A hematoma formed around the nail and was opened 
on July 10, 1 9 14. No fever at any time. The nail will be re- 
moved about July 20, 1914, about five weeks after the operation. 
—Ed.] 



POSTOPERATIVE VENTRAL HERNIA FOLLOW- 
ING APPENDICEAL ABSCESS.— IMBRICA- 
TION OPERATION 



HISTORY 

The patient, an unmarried man aged forty-five, entered the 
hospital with the following history: In May, 1909, he was op- 
erated for acute appendicitis. The abdomen was opened in the 
median Hne, the incision being below the imibilicus and above the 
symphysis pubis, about six inches in length. The doctor told 
him they found the pelvis full of pus. A drain was put in and 
left in for three weeks. He made an uneventful recovery, and 
left the hospital at the end of five weeks with the wound com- 
pletely healed. 

About one week after leaving the hospital he noticed that in 
rising from a sitting position a bulging appeared in the site of the 
incision. He consulted his doctor, who advised him to wear a 
tight binder until the abdominal muscles were strong. This he 
did for six months, but without avail. Then he returned to the 
doctor, who, after examining him, told him that he had a hernia 
which would have to be operated. 

The hernia has not increased in size since it was first noticed, 
in July, 1909. It does not bother him at stool and has never 
pained him. He has been constipated since the appendicitis 
attack in 1909, but has had no urinary difficulty. He never has 
had any nausea, vomiting, chills, or fever. 

Three days after the operation, in May, 1909, his right leg 
became swollen from the foot to the hip. The foot was kept 
elevated, on the doctor's advice, and the swelling left him three 
weeks after the onset. He has not lost any weight recently, and 
feels in good health. 

The hernia is in the site of the old operation scar and is about 
six inches in diameter. 

861 



862 CLINICS OF JOHN B. MURPHY 

COMMENTS AND OPERATION 

Dr. Murphy (April 25, 1914) : That is a classic history for a 
ventral hernia. The man had a suppurating appendix which 
poured pus into the abdomen, drained for a long time, and re- 
sulted in a weak scar in the abdominal wall, in which a large 
ventral hernia developed in the long axis of the scar. On ac- 
count of the oval shape' of the hernia we shall overlap the flaps 
laterally in place of overlapping them from above downward, 
as you saw us do in a somewhat similar case yesterday. 

In the treatment of these ventral hernias the important 
element is the condition responsible for its development. Pre- 
vention is always better than cure, and an early cure better than 
a late one. After an operation for acute appendicitis or for some 
other abdominal lesion, especially those necessitating prolonged 
drainage, the patient develops a protrusion which at first may be 
not larger than the end of yoiu: thumb. That is the time to 
operate. That is the time to say to the patient and his friends, 
**This wound has not united. It must be resutured at once." 
Remember that, sterile or septic, one does not always obtain a 
firm wound union, and the operator is not, necessarily, respon- 
sible for the failure. But the admission of the fact to the patient 
and his people at once permits you to perform the required opera- 
tion, when that operation is a very simple matter. If one waits 
until the hernia develops to large size or until it reaches the size 
of the hernia we operated yesterday, the operation becomes 
serious, not because of difficulty in the technic, but because of 
serious complications which may affect the final result. The 
operation for large ventral hernias has a colossal mortality. To 
some of you that statement may be a surprise. It is not a greater 
surprise to you than it was to us on one occasion. We were 
operating in the upper operating-room of this hospital, where we 
are in close contact with the visiting doctors, when one of the 
visitors asked me, ^* What is your mortality with ventral hernia?'* 
This was twelve or fifteen years ago. "Why," I replied, " I have 
never seen a death from a ventral hernia operation." "Well," 
he said, "I have just returner! from New York, and I saw three 



POSTOPERATIVE VENTEAL HERNIA 863 

patients operated there for ventral hernias and all three died." 
The patient on whom we were then operating was a woman under 
forty, apparently in splendid health except for the ventral hernia. 
She was dead at eight o'clock the next morning. She is the only 
patient we have ever lost from this operation. Of what did she 
die? Of just what the great majority of these patients die, 
pulmonary edema. Why? Because, when you perform an 
operation for ventral hernia, particularly a large ventral hernia 
in the upper abdomen, you put the piston of respiration, which 
is the diaphragm, out of commission. The contracting dia- 
phragm is held voluntarily in abeyance because its movements 
increase the tension on the abdominal stitches and cause pain. 
Therefore the diaphragm makes shorter and shorter excursions, 
still further embarrassing a circulation already compromised 
by the increased abdominal pressure produced by the overlapping 
flap operation and postoperative tympanites, and finally the 
patient develops a hypostatic edema of the lower lobes and soon 
dies, as by drowning. A bloody, frothy fluid commences to flow 
out of his mouth in increasing amounts, as I have seen it on three 
different occasions. This pulmonary edema is more frequent 
when the operative attack is in the upper abdomen than in the 
lower abdomen. I believe the anesthetic has nothing to do with 
the causation of the edema. We have learned to elevate the foot 
of the patient's bed from eight to twelve inches after these opera- 
tions. In that position the fluid flows out of the patient's mouth 
instead of stagnating in his lung and slowly drowning him. These 
patients are also given j^ grain of atropin once or twice a day 
until they are over the danger period, which is usually about 
forty-eight hours in duration. The rule is that they die very 
promptly, if they die at all. Because of this danger of sudden 
fatal pulmonary edema these cases give one very serious concern. 
If you have never had a case of edema of the lung, you have 
missed a very disturbing experience. I remember one of my 
earliest cases. I had been practising only a short time, but had 
fortunately had instruction in school on the subject. The lec- 
turer who described to us this condition said he had frequently 
seen it in northern Michigan, where he first had practised. A 



864 CLINICS OF JOHN B. MURPHY 

man who had been riding for a long distance in severe cold weather 
on an open sleigh would come into the house and sit by the stove. 
In a little while he would have some difficulty in breathing, then 
more difficulty. He would soon become cyanotic, a bloody 
fluid would flow out of his mouth, and he would die. That, we 
were told, was a common occurrence in northern Michigan and 
Wisconsin in the early logging days. 

This early patient of mine was a man who had been out riding 
in a sleigh on an exceptionally cold day. He came in the house 
and sat by a grate fire. His breathing commenced to become 
difficult, and so his brother called me. When I saw him I told 
his brother that he was going to die and die promptly. He was 
then sitting in a chair talking to me rather unconcernedly, ap- 
parently not very ill, except that his breathing was difficult. 
That was four o'clock. He was dead at 6.30. The acute pul- 
monary edema showed itself in the bloody, frothy fluid which 
flowed out of his mouth. I never do a ventral hernia that I do 
not think of that case. 

Now, then, as to the technic of the operation for ventral 
hernia. For many years it was the custom to expose and freshen 
the edges of the cicatricial tissue bounding the hernial defect and 
unite these edges. That procedure resulted almost uniformly 
in failure, because the connective-tissue borders did not unite 
organically. That line of suture commenced to stretch and 
spread imtil the hernia was back again. Then came the method 
of fixing the approximated edges with double sutures. Finally 
came the Mayo method — the overlapping flap. In the beginning 
it was the custom in the flap operation to free and unite separately 
the peritoneimi. That technic has been abandoned. The peri- 
toneum now is kept on both the external and internal flaps. 

This patient will be kept in bed for five weeks following the 
operation. For the first three weeks he will be kept perfectly 
quiet. We do not let these cases up early, as we do the cases 
operated for inguinal hernia. In ventral hernia vigorous tissue 
reaction and tissue regeneration are necessary for success. 
They cannot be stimulated or hastened by any invention now 
known to us, any more than a sixty-day corn can be grown in 1 liirty 



POSTOPERATIVE VENTRAL HERNIA 865 

days. It takes at least thirty days for these tissues properly to 
regenerate and organically to unite. Until that occurs there 
must not be severe tension on or stretching of the tissues. 

We use chromicized catgut for the deep sutures in these cases. 
We feel fairly well satisfied with the chromicized catgut which we 
use for these stitches, and have had no trouble with it. We have 
had only one accident with catgut in a great many years. That 
occurred following an interval appendicitis operation. The 
patient, on the seventh day, developed tetanus. She was a farm 
girl, and had had much to do with cattle and horses; so we be- 
lieved at the time that the preliminary disinfection of the skin 
was not sufficiently thorough, and that her tetanus bacilli came 
from that source. Two months later, however, I received a 
letter from Calcutta, India, saying, "Doctor, on your recommen- 
dation we used such and such a catgut, which was shipped to us 
from the factory on such and such a day. Following the use of 
the first package we had three cases of tetanus develop, one of 
whom died." The factory date he gave corresponded exactly 
with the date on which we received our tetanus-infected catgut. 
Whether it was a special intervention of Divine Providence that 
sent me that letter from Calcutta I do not know. At any rate, 
it lifted the responsibility for that infection from our shoulders. 
From the use of the balance of that order of catgut nothing un- 
toward occurred. We had used it all before receiving the letter, 
and we went right on using the same catgut subsequently without 
any further ill results. Something must have happened in the 
preparation of that particular lot of catgut — some slip in the 
preparation that produced a contamination. That is the only 
serious catgut accident we have ever had. You remember they 
had rather a serious situation with it in St. Louis many years 
ago. 

We put the patients in these ventral hernia cases to bed with 
the feet elevated, because that puts the least possible tension on 
the line of suture. The painful tension on the line of suture is 
one factor in the difficulty in breathing which these patients ex- 
perience. In the operations in the upper abdomen performed 
under local anesthesia the percentage of pneumonia is practically 
VOL. m— 55 



866 CLINICS OF JOHN B. MURPHY 

identical with that in the cases operated under general anesthesia. 
That is one of the reasons why we do not use local anesthesia. 

[Incision.] 

In making the incision we endeavor to excise the scar tissue 
in the skin due to the former operation. I am preparing the 
aponeurosis of the rectus muscle to form a lateral flap and shall 
use it over the entire length of the defect. Now we cautiously 
open the peritoneum, since we cannot tell beforehand whether 
the intestines are adherent or not to the parietal peritoneum, and 
we must run no chance of accidentally opening them. 

[The peritoneal incision opened into the free peritoneal cavity 
without accident. The line of incision was fortunately chosen, 
because just medial to it lay a line of adherent intestine into 
which it would have been unpleasant to open. These adhesions 
were separated. The raw surface on the parietal peritoneum 
was excised, and a flap of peritoneum mobilized and pulled over 
the defect. The raw surface on the intestines was covered by 
infolding. — Ed.] 

Here you see the line of adhesions at the position where the 
abdomen was opened. Fortunately, this is not an old wound. 
It is a very good wound, from an, operative standpoint; that is, 
there is only a small number of adhesions present, comparatively 
speaking. There are some diverticula and pockets here below 
the hernial opening, especially in the direction toward where the 
appendiceal abscess was situated. As we approach the caput 
coli everything is adherent. We must free the aponeurosis until 
we reach the margin of the rectus muscle, which you see here. 
The left aponeurotic flap will be placed underneath the flap from 
the right. We freshen the margins of the hernial opening, but 
only a Uttle. 

Let the record show that there was no large diverticulum, 
only small ones, present in the hernial mass. 

[The wound was then closed by overlapping flaps of rectus 
aponeurosis covered by peritoneum.] 

That is to all purposes practically the Mayo operation. 
The overlapping procedures of the operation represent almost 
exactly the imbrication operation of Andrews for inguinal hernia, 



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POSTOPERATIVE VENTRAL HERNIA 869 

and, with the exception of the added factor of the spermatic 
cord, the overlapping flaps are placed much as in Bassini's opera- 
tion for inguinal hernia. The technic seems slow, because the 
operator has to do most of the work himself. 

The foot of the patient's bed will be elevated twelve inches. 

Let the record show that a double overlapping flap of rectus 
aponeurosis was prepared, that the right flap passed under the 
left, and that the peritoneum was left on the under surface of 
both flaps. 

[Note. — Forty-eight hours after the operation the patient 
began to vomit. The vomiting increased, and the patient's 
stomach was irrigated repeatedly. The vomiting continued, 
the patient became dyspneic, cyanotic, and then livid. The 
pulse-rate went up rapidly, and he died twenty-four hours after 
the onset of the symptoms. He did not develop an edema of 
the lungs. This is the second death following the operation for 
ventral hernia which Dr. Murphy has had in his entire experi- 
ence. No autopsy was. granted and, therefore, the cause of 
death is not absolutely certain; but the symptoms were those 
of a sudden cardiac breakdown, whether due solely to some 
complication of the operation or partly or wholly to myocardial 
disease, we do not know. We do know that the patient had no 
valvular disease. — Ed.] 



4) 



'\ 



THE CLINICS 

OF 

Volume III JOHN B. murphy Number 



MURPHY'S CLINICAL TALKS ON SURGICAL 
AND GENERAL DIAGNOSIS 

A DIAGNOSTIC TALK ON THE SYMPTOMS AND SIGNS 
OF RENAL AND URETERAL STONE, ILLUSTRATED 
BY A CASE 

HISTORY 

The patient is an unmarried man, aged thirty-eight years. 
His family history is negative. His past history is negative ex- 
cept for rheumatism, which he had in 1907, and which laid him 
up in bed for six weeks. 

The patient has been otherwise perfectly well until Wednes- 
day, April 15, 19 14. At about 8 a. m. on that day he was sud- 
denly taken with a severe, sharp pain in the left loin, which lasted 
about thirty minutes. During this attack of pain he felt nause- 
ated, but did not vomit. The pain was steady and continuous, 
and did not radiate or change its location. He felt well the rest 
of the day, except for slight weakness. He noticed no further 
symptoms until nearly midnight on Friday, April 17, 19 14, when 
he was awakened with the same pain in exactly the same location 
as the previous attack. This pain lasted twenty minutes. After 
it stopped he became nauseated and vomited once. He felt 
well Saturday until 2 p. m., when another attack came on suddenly 
the pain being more severe than at any previous time. He be- 
came nauseated and vomited. The pain continued severe imtil 
Sunday noon, and then it became somewhat less and seemed 
lower down. On Sunday evening, April 19, he noticed tenesmus 
of the bladder for the first time. Saturday and Sunday he had 
frequent urinations, and thinks that on Sunday the pain radi- 
ated into the left thigh. He never passed blood at any time, 
and, so far as he knows, had no chills or fever. 

COMMENTS 
Dr. Murphy (April 20, 1914): The patient came into the 
hospital complaining of severe and intense pain in the left side, 
coming on suddenly without a moment's warning. 

871 



872 CLINICS OF JOHN B. MURPHY 

There is no blood in the patient's urine today, and none has 
been found since he entered the hospital. This attack occurred 
on Saturday night. Today is Monday. He had immediately, 
on entering the hospital, one physical sign which is very indicative 
of distention of the renal pelvis — intense pain on fist percussion 
over the left lumbar region. This symptom was never more 
beautifully shown than by this patient, and I could not demon- 
strate it in a case where it could have had greater diagnostic 
value, because of the vagueness of the other focal symptoms and 
because of the absence of blood in the urine, which is so commonly 
an important diagnostic point in renal and ureteral calculus. 
This symptom was present just at a time when there was no 
other physical sign of localizing value. Where there is an acute 
infection of the kidney, with a sudden distention of the renal 
pelvis, or capsule, there is always, on deep fist percussion, the 
same very severe pain. This infection may be either ascending, 
a pyelitis or pyelonephritis, or hematogenous, an embolus. I 
think I have never been so much impressed with the value of the 
test, as in this case. I have been enthusiastic about it for years, 
but in the other cases we have always had some confirmatory 
evidence pointing to the kidney as the seat of trouble, when we 
came to examine the urine. Here we had nothing of confirma- 
tory value from the laboratory, and so we had to rely entirely 
on the history and this one physical sign, which, when so beauti- 
ful and clean-cut as in this case, aids one greatly in differential 
diagnosis. It is especially valuable in differentiating between 
the three common sites of lesions occurring acutely in the right 
side of the abdomen, the gall-bladder, the appendix, and the kid- 
ney. Where the test is positive on the left side of the abdomen, 
one can differentiate between pathology in the pancreas and in 
the kidney on that side. One of the great advantages of this 
test is that it often enables one to make the correct diagnosis of a 
case at the patient's bedside, without the delay incident to 
laboratory examinations; and, therefore, it conduces to prompter 
and more efficient therapy. See how this case contrasts with 
the case of perinephritic abscess we recently had! (See this 
issue of the Clinics.) That woman had a clean-cut history of 



CLINICAL TALKS ON DLA.GNOSIS 873 

an infection a month after an abortion, a chill preceding the 
pain, with few leukocytes in the urine, local sensitiveness in the 
loin, and the continued, relatively high temperature of a severe 
infection. This man had his pain first, than a slight elevation of 
temperature. He also had that pecuHar chilly feeling common 
with severe pain; but he did not have a genuine severe chill. 
Laboratory examination failed to reveal any blood in his urine, 
a negative feature rather characteristic of a stone starting to pass 
down the ureter. This is Monday. The attack set in on Satur- 
day night. The patient still has pain this morning, but the 
pain has crept downward and now is situated just at the brim 
of the pelvis, on the left side. The stone has, therefore, been 
working downward in the ureter, and will probably soon pass into 
the bladder, and then blood will appear in the urine. If the stone 
cease to advance, the coHc will stop. The pain of ureteral stone 
is a colicky pain. Colicky pain, however, is produced not only 
by the passage of a renal calculus, but also by a fecal concretion 
or a hepatic calculus. Whatever the variety of the calculus, so 
long as it advances it causes pain, and when it stops, the pain 
ceases. 

The causation of pain by a calculus also predicates, as a rule, 
its being large enough to cause some degree of obstruction to the 
lumen in which it Hes. A stone may remain for weeks or even 
years in the ureter without the recurrence of a colic. The pain 
returns when the stone starts moving. That is a feature of 
great diagnostic moment which we must constantly bear in mind. 

Note. — The patient was put on medical treatment and re- 
mained in the hospital for about two weeks without having a 
further attack. He then returned home, and has had no trouble 
since. He passed no stone and no blood during his stay in the 
hospital. The stone is probably suspended somewhere along the 
ureter. Repeated x-xdcy examinations were negative, the patient 
being very fat, and the stone probably a uric-acid calculus and 
small. — Ed. 



874 CLINICS OF JOHN B. MURPHY 



THE DIFFERENTIAL DIAGNOSIS OF THE CAUSES OF 
HEMATURIA. ROUTES OF METASTASIS AND CLIN- 
ICAL COURSE OF MALIGNANT TUMORS OF KID- 
NEY AND TESTIS 



HISTORY 

The patient, a housewife aged sixty, entered the hospital 
originally February 12, 191 2, with hematuria as her chief symp- 
tom. 

Her family history is negative as to malignancy and tubercu- 
losis. She never has been associated with a tuberculous person 
to her knowledge. Her menstrual history is normal. She had 
the menopause at the age of fifty, and has never menstruated 
since. She has six living, healthy children. 

In September, 191 1, five months ago, she began to have pain 
at times in the right lumbar and iliac regions. This pain bore 
no relation to the menses, which had stopped long before. It was 
sharp and aching, and radiated down the thighs. It never be- 
came acutely agonizing or coHcky at any time. The urinations 
were accompanied by pain, and the amount of urine was in- 
creased, the patient going to the urinal several times every 
night. In September, 191 1, a small amount of blood was voided 
with the urine for the first time. The amount was less than half 
a glassful. The passing of blood, together with the pain, caused 
her to consult a doctor. 

In November, 191 1, she had a very severe attack of pain in 
the middle of the night and vomited several times. In January, 
191 2, about the first of the month, she passed enough blood per 
urethram to fill a quart bottle. Since then she has been so weak 
that she has stayed in bed constantly. 

Her right iliac region and the region just above and to the 
outside of it are the seat of the greatest tenderness and pain. A 
tumor mass is present in this location. She had a chill one week 
before entering the hospital, but does not know as to fever. Her 
temperature was normal on entering the hospital. 

Examination of the chest reveals a well-marked pigeon 
breast. The heart is free from pathologic findings. 



CLINICAL TALKS ON DIAGNOSIS 875 

Cystoscopic examination on February 13, 191 2, showed very 
little congestion about the opening of the right ureter, but a 
blood-clot could be seen escaping from it. There was no erosion 
or congestion of the left ureteral opening. It was decided that 
there was not sufficient evidence at the right ureteral opening to 
justify a diagnosis of suppuration of the kidney. The ureters 
were then catheterized, and 20 c.c. of urine was obtained from 
each one. The urine from the right side was much the more 
cloudy. The laboratory findings were as follows: 

Urine from the left kidney: Numerous red cells are present 
— about 30 to a one-sixth objective field; leukocytes, 6 or 7 in a 
one-sixth objective field; a few granular casts are also present. 

Urine from the right kidney: Erythrocytes, from 12 to 16 in 
a one-sixth field; leukocytes, from 4 to 6 in a one-sixth field; 
no casts were found. 

Cultures showed the presence of Staphylococcus albus in the 
urine. On repeated examination the tubercle bacillus was not 
found. 

A blood count showed 8,000 leukocytes; erythrocytes, 
3,040,000; hemoglobin, between 60 and 70 per cent.; blood- 
pressure, no mm. of mercury. 

An examination of the voided urine made on February 12,1912, 
showed a small amount of albumin; no sugar; a few finely gran- 
ular casts; an occasional red blood-corpuscle; a few white blood- 
cells; some vaginal epithelium. The specific gravity was 1015; 
the reaction, acid. Examination of the urine on the thirteenth 
of February was of the catheterized specimens reported above. 
An agar slant was inoculated with sediment from the left kid- 
ney and showed numerous colonies after eighteen hours. The 
urine from the right kidney showed only three colonies. Exam- 
ination of the colonies showed a pure culture of Staphylococcus 
pyogenes albus. Examination of the urine on February 15 
showed a specific gravity of 1030; an acid reaction; albumin 
present; no casts; no sugar; numerous red blood-corpuscles; 
few white blood-corpuscles; some vaginal epithelium. 

The patient was operated on February 14, 191 2. An in- 
cision was made below the twelfth rib on the right side, passing 



876 CLINICS OF JOHN B. MURPHY 

downward, and forward. The kidney was grasped and pulled 
into the field, and the pelvis of the kidney was exposed. The 
proximal end of the ureter was found to be dilated. Pulsating 
vessels were found running into the pelvis of the kidney and in 
front of the ureter just where it comes out of the pelvis. The ves- 
sels and ureter were Hgated and cut. The kidney was found 
to be enlarged and nodular. It was freed from the surrounding 
structures and removed. One rubber drainage-tube was inserted 
to the bottom of the wound, and the skin closed about it in the 
usual way. 

Examination of the excised kidney showed it to contain large 
tumor masses, almost caseous in appearance, near the pelvis and 
also in the cortex. Grossly, the tumor looked Uke a hyper- 
nephroma. The tumor was sent to the laboratory for section 
and microscopic diagnosis, and was reported by Dr. Zeit to be a 
hypernephroma. 

The stitches were removed on February 23, but the tube 
was left in. There was a serosanguineous discharge present, 
without urinous odor. The tube was removed on March i. 

The patient entered the hospital again on March 27, 1914. 
She tells us that since the operation in February, 19 12, up to the 
present time she has had dull, continuous pain all through the 
right side of the abdomen and chest and also in the right arm 
and right leg, extending in the lower limb along the inner side 
of the thigh clear to the foot. Both the arm and leg feel numb 
and weak. About February i, 19 14, she had a sudden severe 
attack of sharp pain, referred to the bladder and urethra, while 
trying to urinate. She could not void the urine, so she put a hot- 
water bottle over the bladder and the urine passed at once. At 
the same time she voided a small clot of blood. She has passed 
no blood since that time. She had no chills or fever at this time 
and has had no pain in bladder or urethra since then. However, 
she has had sharp, irregular pains, shooting in character, in the 
right side of the abdomen and in the lumbar region, radiating 
posteriorly beneath the scapula and into the right shoulder. 
About one week after the onset of the sharp pains referred to 



CLINICAL TALKS ON DIAGNOSIS 877 

above (i. e., February 8) she began to expectorate blood morn- 
ings, and continued to do so for about two weeks. About March 
I, 19 14, at midnight, she awoke suddenly and was very dizzy. 
She could not stand and felt very weak. Immediately there- 
after she had emesis, but no blood was noted in it. She had 
emesis three or four times during the night, but not since then. 
At times, when turning from the right side over to the left, she 
has a sensation as if a mass in her abdomen moves to the left, 
and then back again to the right when she turns back. She 
has had no actual chills, but often has chilly sensations. She 
has had no unusual perspiration. She knows nothing as to her 
temperature, and has lost but Httle weight. 

Urine examination: Specific gravity, 1020; no albumin; no 
sugar; an occasional granular cast; about 30 white cells to the 
field of a one-sixth objective; no red cells. 

A white cell count showed 9400 leukocytes. 

COMMENTS 

Dr. Murphy, April, 19 14: Let us have again the history 
preceding the first operation. 

(Intern reads the history.) 

Dr. Murphy: That is a misstatement, I believe, as to the 
amount of urine being increased. The last statement regarding 
increased frequency does not justify the conclusion that the 
amount was increased, as the intern who wrote the history ap- 
pears to have thought, because urination often is increased in 
frequency, but the amount of urine not increased. The amount 
may be diminished and yet the frequency increased. The intern 
had no right to draw that conclusion from the patient's story 
unless he has actually measured the quantity and knows it to be 
increased. 

The cystoscopic examination in February, 191 2, showed us 
pretty definitely from which kidney the blood came. It was from 
the right side. Further, there was no redness, congestion, or 
edema about either ureteral orifice. The examination of the sep- 
arated urines obtained by ureteral catheterization was misleading, 
more blood appearing from the left than from the right ureter as 



878 CLINICS OF JOHN B. MURPHY 

a result of the trauma to the left ureter by the catheter. It is 
this accidental hemorrhage due to shght tears of the ureteral mu- 
cosa which compels one to be so careful about interpreting the 
presence of blood in specimens of urine obtained by ureteral cathe- 
terization. But we actually saw the blood coming from the right 
ureteral orifice before we introduced the catheter. Therefore it 
was easy to tell that the right kidney was the one which had been 
bleeding. It was on this side that the tumor lay. This com- 
plaint is very similar to what? To her present complaint, except 
that she had her previous hemorrhage during the attack of pain. 
She had the first pain in September, 191 1, and the hemorrhage in 
November. That hemorrhage was of such large quantity that it 
exsanguinated her, ran the erythrocytes down to 3,040,000, with 
a hemoglobin of from 60 to 70 per cent. That gives an index of 
0.8 +, which is about right for a secondary anemia of moderate 
degree. 

What is the most common cause of bleeding from the kid- 
ney? It is a stone. Now, although she had a history of coHc 
at this particular time, she had a very profuse hemorrhage, 
which is not commonly the case with stone. With stone you 
may have the blood in sufficient amounts to see it with the naked 
eye, but you do not commonly have it in such quantities that it 
fills a basin. She has no colic except the coHc at the time of the 
bleeding, just as now, which means what? That the blood is 
passing in clots through her ureter. I will show you later another 
case which belongs in this class, and which will give you a good 
picture of the class. 

Another condition which frequently causes blood in the urine 
is renal tuberculosis. It is usually associated with frequent uri- 
nation, which is commonly the primary symptom. You will 
remember the intern said she had a larger quantity of urine, a 
point which we did not concur in, because we said he had no right 
to make such a statement. Then we made the tuberculin test 
and a guinea-pig injection, both of which were negative. We 
examined the urine repeatedly for tubercle bacilli, but none were 
found. That is not at all uncommon with tuberculosis, especially 
with cortical tuberculosis of the kidney. Remember, you can 



CLINICAL TALKS ON DIAGNOSIS 879 

have great hemorrhages with cortical tuberculosis where the 
tuberculous ulcer is not opening into the renal pelvis and no 
bacilli are present. You are less likely to have hemorrhage when 
the tuberculosis is in the renal pelvis. Kidney tuberculosis may 
begin in any one of three positions: first, the cortex; second, 
the pyramids; third, the calices or mucous surface of the pel- 
vis of the kidney. With the lesion in any one of these three 
locations, you may have increased frequency of urination. You 
never find tubercle bacilli unless there is an opening between the 
focus and the pelvis of the kidney, and so the tubercle bacilli 
in the urine may be a very late manifestation of tuberculosis of 
the kidney, just as it is often a very late manifestation of tuber- 
culosis of the lung. But you have the tuberculin test, which, 
with an active tuberculosis to the degree of ulceration, should 
give a high febrile reaction the next day. That test was negative. 
That excluded tuberculosis. Still further to exclude a tuber- 
culosis, you have the appearance of the ureteral opening at the 
cystoscopic examination. There was no congestion at its mouth 
or at the internal urethral orifice, as is so commonly present with 
tuberculosis. 

Malignant tumors of the kidney are a very common cause of 
hemorrhage. First in frequency is the hypernephroma; next, 
the sarcoma; next, the carcinoma. Then you can have hemor- 
rhage from the more innocent types of tumor which occur in the 
kidney. 

Now, to come back to the patient: We told you what we did 
in the first operation. She says she has pain now in the right 
side of the abdomen, a little in front and a little behind. But 
she has the most pain in the upper right quadrant of the abdo- 
men. That also is where she is most sensitive. 

Now, you might think of a kidney tumor, but the right kid- 
ney is out in the laboratory. That is the point I want to make. 
Therefore the tumor cannot be in her right kidney. In this con- 
nection I should like to mention another case. Have you the 
history of the physical findings in the abdom^en in Dr. Golden's 
case of sarcoma of the testicle? 

Intern: There were no positive physical findings in the 



88o CLINICS OF JOHN B. MURPHY 

abdomen in Dr. Golden's case; nothing was found until the op- 
eration. 

Dr. Murphy: I want to bring in that case because it is a 
beautiful one to contrast with this. Dr. Golden's case had the 
lesion on the left side. Read the history. 

HISTORY (Dr. Golden's Case) 

Patient, male, aged fifty-eight, married, entered the hospital 
March 13, 1914. 

No tuberculosis or cancer in the family; wife has had no 
miscarriages. Patient had typhoid fever six weeks ago. He 
was operated twenty-three years ago for hemorrhoids. He de- 
nies all venereal disease. 

About June i, 19 13, he first felt the left testicle very hard 
and slightly larger than the right. It could be squeezed firmly 
without producing any pain at all. It continued to grow larger 
until three months ago, when it reached the size of a hen's egg 
and was somewhat flattened. He consulted a doctor, who ad- 
vised its removal, but made no diagnosis. Since that time it has 
increased more rapidly in size, so that now it is the size of a 
large orange, somewhat flattened and nodular, but not adherent 
to the skin. About February i, 19 14, the left inguinal glands 
became enlarged and at times are painful, especially in walking. 
There is no involvement of the other testicle, and there has been 
no bladder or urinary trouble at any time. His bowels are not 
constipated. 

An incision was made into the enlarged testicle and a speci- 
men sent to the laboratory for diagnosis on March 14. It was 
diagnosed as a large round-cell sarcoma, with perhaps a trace 
of alveolar arrangement. 

On March 15 he was again operated and the left testicle 
enucleated and sent to the laboratory to confirm the diagnosis 
of sarcoma. The scrotum was closed without drain. An an- 
terior incision was then made over the left renal area and the field 
inspected for enlarged glands. These were found and removed 
and sent to the laboratory. The glands showed extensive met- 
astases. • A rubber drain was inserted. 



CLINICAL TALKS ON DIAGNOSIS 88 1 

Dr. Murphy: How large were these glands? 

Intern: Just about the size of a walnut; and they were 
situated just below Poupart's ligament. 

Dr. Murphy: How many were there? 

Intern: I do not remember. 

Dr. Murphy: There was no tumor in the abdomen? 

Intern: No tumor was felt in the abdomen. 

Dr. Murphy: What was the doctor's diagnosis? That it 
was a sarcoma. If it was a sarcoma, why should he have an en- 
largement of the glands in the groin? Sarcoma is not trans- 
mitted through the lymphatics, as a rule. It is transmitted 
chiefly through the blood-vessels. That is the rule. The ex- 
ception to the rule is the left testicle. Think of it ! It shows you 
how important it is to know. From the left testicle the sarcoma 
cells may be transmitted through the lymphatics and appear in 
the lymph-glands below Poupart's ligament; but the most com- 
mon place in which they are arrested in their spread from the 
left testicle is in the gland on the left renal vein. Unless you 
go after that gland there is no use in doing an operation for the 
removal of a testicle sarcoma which has been present so long as 
this one was present. When Dr. Golden took out the testicle 
and saw there was a sarcoma, he did a laparotomy at once and 
took out the glands which were situated on the left renal vein. 
You can see that an amputation of that man's testicle alone would 
not be of any benefit to him. A removal of the glands on the 
anterior surface of the renal vein was of the utmost importance in 
the attempt to save his life. He had no urinary findings, no evi- 
dence of an abdominal mass, thus showing the bladder was not 
involved by the afifection; and yet, from our clinical experience, 
Dr. Golden felt that the renal glands were probably involved in 
this type of tumor, opened the abdomen, found and removed 
them. 

Let us come back to this case before us. This woman had a 
hypernephroma of the right kidney. The kidney was removed. 
H3^ernephromata do not, as a rule, attack the glands in the 
neighborhood, but do occasionally pass into the more distant 

VOL. Ill — 56 



882 CLINICS OF JOHN B. MURPHY 

lymphatics, and can be arrested in the glands into which these 
drain. More frequently, however, metastasis takes place by 
the blood-stream in distant organs, first in the lung, but also 
commonly in the other kidney. Sarcoma almost always recurs 
in the other kidney if the patient lives a period of three years. 
There are only a few authentic exceptions to this rule in the entire 
literature of sarcoma of the kidney; and, remember, we included 
hypernephroma with sarcoma of the kidney until very recently. 
Within the last third of a century and until the last ten years 
h}T)emephroma was called sarcoma. When I looked up the 
literature some ten years ago there was not a single authentic 
case of sarcoma of one kidney which did not recur eventually in 
the other. That fact suggests what? The recurrence of this 
hypernephroma on the right side, either in the connective tissue 
or in the blood-vessels. You will often find a protrusion of the 
tumor into the renal vein. In hypernephroma which begins in 
the pelvis of the kidney, you frequently find extension into the 
renal vein. It is easy to put on a clamp and cut off the renal 
hypernephroma and yet leave that portion of the tumor which 
is in the vein. You cannot follow the tumor any farther at oper- 
ation. You often have secondary manifestations in the lung, 
but recurrences in the other kidney are almost equally common 
manifestations. Whether it is by lymphatic transmission or 
blood transmission we do not know, but the clinical fact is that 
it occurs in the other kidney. It occurs also in the liver, the 
spleen, the bones, and in other tissues. 

Now, this patient has commenced to have the same t^ain 
of symptoms from the left kidney that she had originally with 
the right; but in addition she has what? The expulsion of 
blood-clots. She has blood in the urine. She has colic. She 
will run along probably for from one and a half to two years and, 
finally, depending on the size of the growth, she will die from her 
hypernephroma; but you want to know the pathologic course of 
the disease in order to know what to do. She came in today for 
a removal of the tumor on her left side. It will not do to go in 
and take out that tumor on the left side because of the bleeding 
from the kidney. The bleeding is not from the right side. It is 



CLINICAL TALKS ON DIAGNOSIS 883 

from the left side; so a radical operation of any type would be 
positively unjustifiable so far as this condition is concerned. That 
is one of the reasons for having her here this morning, to impress 
on you the clinical course of these cases, and to show you that 
your knowledge of the natural clinical course aids you in keeping 
this patient out of additional suffering from mistaken surgery. 
You have to give an unfavorable prognosis, but then you did 
not make the hypernephroma, and that it means death to the 
patient is not your fault. That is a beautiful case to work out, 
but a few such cases are enough for a Hfetime. 

A recent thoroughgoing study of the pathology, pathogenesis, 
and routes of metastasis in hypernephroma which I can recom- 
mend highly to those surgeons who are so fortunate as to have 
a reading knowledge of German is that of Kostenko, ^'Zur 
Kenntniss der Hypernephrome," in the Deutsche Zeitschrift fur 
Chirurgie for 191 1, vol. cxii, pp. 284-367. The recent theories 
as to the origin and nature of malignant tumors of the kidney are 
subjected here to a thorough discussion based on a splendid 
material and a painstaking consideration of all the related de- 
tails. 

[May 8th: No subsequent operation or death yet.] 



INTRATHORACIC SARCOMA STARTING FROM THE 

VERTEBRAL COLUMN.— DIFFERENTIAL 

DIAGNOSIS 

EXAMINATION AND DISCUSSION BY 
DR. CHARLES L. MIX 



HISTORY 
The patient, a married man, aged forty-seven years, entered 
the hospital April 26, 1914, with the following history: His family 
history is negative to tuberculosis. His wife and five children 
are living and well. His wife has had no miscarriages. The 
patient's previous history is negative. He denies venereal in- 
fection. 



884 CLINICS OF JOHN B. MURPHY 

The patient's present illness began as follows: About De- 
cember I, 19 13, he began to have coughing spells which would 
last about ten minutes, as a rule. This cough was dry and un- 
productive. The paroxysms of coughing were especially prone 
to occur after retiring for the night, and they often kept the 
patient from sleeping, because of their severity and frequency. 
This condition continued until about Christmas, 19 13, when he 
noticed, for the first time, pain in the upper right quadrant of the 
abdomen, dull in character. The day after Christmas the pain 
became worse and radiated from the upper right quadrant of 
the abdomen to the epigastrium, and also around to his back and 
up under the right scapula, then passing diagonally up the chest. 
This pain has always been increased by deep inspiration. In 
the days following the onset of the illness the pain in the hypo- 
chondrium remained dull in character, with occasional stabbing 
sensations, always radiating upward and toward the posterior 
side of the thorax These stabbing pains are increased in sever- 
ity when the patient raises his right arm. The pains have never 
radiated downward toward either the lower abdomen or the 
thigh. They have never been cramp-like or colicky in character. 
They bear no relation to the taking of food, to the bowel move- 
ments, or to urination. On the second day after the pain came 
on, the patient noticed great tenderness in the right upper quad- 
rant of the abdomen. The area of tenderness, like the pain, 
also extended to the epigastrium, and, on the right side of the 
body, as far posterior as the vertebral column. This tenderness 
remained fairly constant during the ensuing days and weeks. 
The pain would often remit somewhat, but always came on with 
full severity whenever the patient lay down. For this reason 
he has slept sitting up in a chair for the last two weeks. 

His cough during the weeks following the onset of his illness 
remained as previously described — spasmodic and unproductive. 
On January 18, 19 14, after a severe spell of coughing, he vomited 
and noticed about one dram of bright-red blood in the vomitus. 
He does not know for certain, however, whether this blood came 
from the lungs or from the stomach. The first bowel movement 
following this spitting of blood was also stained with bright-red 



CLINICAL TALKS ON DLA.GNOSIS 885 

blood. Since the first blood appeared he has often raised slight 
amounts of blood from the throat on other occasions. He has 
had piles for the past ten years, which have been especially 
troublesome during attacks of constipation, and the patient has 
often noticed blood on the toilet paper at such times. He thinks 
himself that the blood which appeared in the stools following his 
first bloody emesis may have come from the piles, since he was 
severely constipated at that time. 

For the past few years the patient has had ^'indigestion" and 
"heart-bum," the attacks coming on from one-half to one hour 
after meals. He belches a great deal of gas. He has vomited, 
however, only once as above described. 

On February 23, 19 14, he was operated on (at another hos- 
pital) in the belief that his symptoms were due to gall-stones. 
No stones were found. Adhesions between the gall-bladder and 
intestines were reported present. The doctor told him on enter- 
ing the hospital that he was jaundiced, but the patient and the 
patient's family say that they never noticed any jaundice. The 
doctor found him extremely tender over the gall-bladder on 
perpendicular hammer percussion. A drain was put in the 
wound at the operation and left in for three weeks. Six weeks 
after the operation the wound was healed completely, but the 
pain, tenderness, and cough remained the same as before the op- 
eration. The patient has never had any clay-colored stools, nor 
any chills, fever, or night-sweats. He has never collapsed, 
fainted, or suddenly felt weak or turned pale. He has never had 
any symptoms pointing toward urinary trouble. 

Examination. — Tenderness is marked over the gall-bladder 
region and below the ribs on the right side. No rigidity is 
present in the abdomen. Some rales can be heard over the 
lower lobe of the right lung. There is no sharply localized point 
of tenderness in the abdomen. The lower right chest, both an- 
teriorly and posteriorly, bulges slightly and the spinous processes 
of the vertebral column deviate sHghtly to the left at the same 
level. Fist percussion over the right kidney is negative, but 
over the vertebral deviation and on pressure the spinous pro- 
cesses produce great pain, extending along the ribs to the gall- 



886 CLINICS OF JOHN B. MURPHY 

bladder region. The patient has lost 40 pounds in weight since 
February 23, 1914. 

The x-Ta.y plates show a definite, circumscribed, rather uni- 
formly dense mass in the lower part of the right lung, just above 
the diaphragm, overlapping and apparently closely connected 
with the vertebral column. 

Examination of the blood, made on April 27, 19 14, showed 
11,200 leukocytes, and hemoglobin between 70 and 80 per cent. 

Dr. Mix (April 30, 19 14): The last point mentioned in the 
intern's history is one of huge importance, namely, that the 
patient has lost 40 pounds in weight since the twenty-third day 
of February, 19 14. Such a great loss of weight is invariably 
indicative of infection, hyperthyroidism, or malignancy. Since 
this patient is running little or no temperature and shows no 
signs of infection, and since he has no enlargement of his thyroid 
gland or other symptoms of h3^erthyroidism, the suspicion of 
malignant disease is immediately aroused. 

Before analyzing his history there are one or two statements 
which must be dismissed as being totally irrelevant. One of 
these is the history of indigestion and heart-burn which the pa- 
tient says he has had for the past few years, associated with a 
good deal of belching of gas. We have been unable to find out 
that these things are in any way related to his present malady. 
We must also get out of the way another statement in the his- 
tory which might be the source of some confusion. It will be 
remembered that on the occasion of his spitting up some blood 
in January, 19 14, he had on the next succeeding bowel movement 
manifestations of blood in the stools. At this time the patient 
was very much constipated, and knowing that he had had piles 
for ten years' time, it was perfectly Evident that the blood, which 
was bright red in character, being passed at a time of constipa- 
tion in a patient who was then troubled with piles, clearly came 
from hemorrhoids. 

We are now in a position to analyze his symptomatology. 
The patient is forty-seven years of age, with a negative venereal 
history, having five living children and his wife having had no 




8S7 



CLINICAL TALKS ON DIAGNOSIS 889 

miscarriages. Aside from the indigestion of which he complains 
and the occasional belching of gas, he was in his usual health 
imtil about the beginning of December, 19 13. At this time he 
began to have paroxysmal spells of coughing. This cough was 
dry and unproductive. The paroxysms used to last about ten 
minutes. They were evidently influenced by the posture which 
he assumed, for we learn that the paroxysms were worse after 
he had retired. According to our interpretation, the paroxysms 
were worse because he was lying down. That our interpretation 
is correct is proved by the fact that subsequently he was obliged 
to sit up in a chair most of the night in order to prevent these 
paroxysms of coughing. 

This dry and unproductive cough, undoubtedly brassy in 
character, continued with increasing severity until the culmina- 
tion of the spitting of blood on the eighteenth of January. On 
that day he told me that he was riding along in a cutter when he 
was suddenly taken with a coughing spell. He coughed until he 
vomited, as people often do, and raised some blood, which he spat 
upon the snow. It was thus that he discovered that he spat up 
some blood, because of the bright-red stain which showed. He 
does not know the amount of blood which he spat up, but from 
what he said I would imagine the amount was small, probably 
only a dram or so. Subsequently he spat up more blood and 
since he has been in the hospital he has had occasional paroxysms 
of coughing associated with the raising of very small amounts of 
blood. This spitting up of occasional small amounts of blood 
after violent coughing is very characteristic of malignant disease. 
It is not characteristic of aneurysm. A dry, unproductive, 
brassy cough usually means either an aneurysm or a mediatisnal 
tumor. An aneurysm when associated with hemorrhage is 
usually associated with a single large hemorrhage. A mediastinal 
tumor when associated with hemorrhage is associated with 
numerous small hemorrhages, if the mediastinal tumor be a sar- 
coma. The very fact that in this case there have been repeated 
small hemorrhages is prima facie evidence of the existence in 
this man's case of a mediastinal sarcoma. There is perhaps no 
point in his history which furnishes such conclusive evidence of 



890 CLINICS OF JOHN B. MURPHY 

the diagnosis as this one point, and its diagnostic importance 
cannot be too strongly insisted upon. 

The cough was the first symptom, beginning somewhere 
early in December, 1913. About the end of 1913, somewhere 
near Christmas, pain began to be a symptom of some importance. 
He noticed it when he was lying down. Evidently the prone 
posture had an affect both in producing the paroxysm of cough- 
ing and in producing the attacks of pain. The pain was located 
in the right upper quadrant of the abdomen, and radiated both 
to the epigastrium in front and backward under the right scapula 
up into the thorax. Very important is the fact that the pain 
never radiated down into the right side of the body or into the 
right lower abdomen or into the thigh. This pain, from its 
position, could be due either to some thoracic, some phrenic, 
or some hepatic disturbance. It is not likely to be due to renal 
or appendix disease. 

The patient was able to describe for us the pain. He said 
that at first it was dull and that after a time it became shooting- 
like, especially in his back. He was intelligent enough to be 
able to assure us that it was never cramp-like. By this we are to 
understand that it was not associated with contraction of any 
circular muscle-fibers about any viscus. The fact that the pain 
was not colicky is rather against the suspicion that it was due 
to any disturbance in the gall-bladder or common duct. It is 
also against the idea that it was due to any ureteral disturbance. 
It is also against the idea that it was due to any intestinal con- 
traction. The fact that the pain was not cramp-like again re- 
fers us to the thorax or to the diaphragm for an explanation of 
the pain. 

A point of considerable importance which the intern got in 
taking the history is that the pain was increased when he raised 
his right arm. Such an increase of pain in mediastinal tumor 
and in aneurysm has been frequently noted in the right arm. 
There are numerous cases in medical literature where this has 
served as a diagnostic point in coming to a conclusion as to the 
existence of mediastinal disease. 

Let us summarize these symptoms up to the present point in 



CLINICAL TALKS ON DIAGNOSIS 89 1 

another manner. You will notice that the onset of this condition 
apparently began with a phrenic irritation. You will notice that 
at the beginning of December he had unproductive coughing 
spells, irritative phenomena referable to the diaphragm or the 
pleura. A great deal of the coughing which we meet with is 
really pleuritic or diaphragmatic coughing, being reflex in origin. 
Indeed, I beHeve that reflex pleuritic cough is quite as common as 
reflex bronchial cough. He began having these paroxysms of 
phrenic irritation early in December. The next step in the 
phrenic irritation was the production of pain in the right upper 
quadrant of the abdomen. I interpret this pain as due to a dia- 
phragmatic pleurisy on the upper surface of the diaphragm, be- 
cause this pain radiated around the back up beneath the right 
scapula into the right chest. Moreover, this pain subsequently 
was associated with exacerbations on raising the right arm, prob- 
ably because of a phrenic nerve neuralgia and reflex brachial 
neuralgia. 

There is another very interesting physical finding in his case 
which is not mentioned in the intern's history. He has a dilata- 
tion of his right pupil; that is, his right pupil is larger than his 
left pupil. The first question is whether the right pupil is di- 
lated or the left pupil contracted. The mechanism of pupiflary 
activity is quite simple. The third nerve contracts the pupil, 
a fact which can easily be remembered by recalling that atropin, 
by paralyzing the third nerve, permits the pupil to dilate. The 
sympathetic nerve is the nerve which actively dilates the pupil 
when the third nerve is inactive. In the case of this patient the 
dilated pupil must be looked upon as an active irritative phe- 
nomenon affecting the sympathetic nerve. I think that this 
irritative sympathetic phenomenon is associated with disturb- 
ance of the sympathetic through its connections with the phrenic 
supply. 

Bearing in mind that the first symptom was cough, that the 
second symptom was pain, we are not surprised to learn that the 
third symptom was tenderness. This appeared in the right upper 
quadrant of the abdomen, beneath the right ribs, and extended 
around the spine to the back. This tenderness was constant. 



892 CLINICS OF JOHN B. MURPHY 

On examining the patient recently we found ample explanation 
for this tenderness, in that pressure upon the fifth, sixth, and 
seventh ribs at the point of articulation with the dorsal spine pro- 
duced very considerable pain. Evidently the pain in this region 
is intercostal in type as well as phrenic, and is probably due to a 
disturbance affecting the articulation of these ribs with the back- 
bone, and giving us a hint that the malady from which he is suffer- 
ing is in some way connected with the backbone and the articu- 
lations of these right ribs with the spinal column. We might 
easily infer an osteosarcoma originating from the bodies of the 
dorsal vertebrae at their articulations with the sixth, seventh, and 
eighth ribs. 

On February 23 we learn that an operation was done by his 
home physicians because they believed that he was suffering 
from gall-stones. This diagnosis was based upon the fact that 
there was pain beneath the right rib, that there was tenderness 
over the gall-bladder on perpendicular percussion, and that there 
was jaundice. These symptoms are not sufficient for the diag- 
nosis of gall-stones. There were no attacks of fever or chills or 
sweats. The jaundice is open to a good deal of question. Ac- 
cording to the patient and the patient's family, he was not 
jaundiced. The physician was the only one who noticed the 
jaundice. In favor of the patient's statement is the fact that 
clay-colored stools were never present. Of course, jaundice is 
not essential to a diagnosis of gall-stones since it appears in only 
50 per cent, of the cases. Still it was evidently used as a diag- 
nostic point in this man's case, though not associated with clay- 
colored stools. It is, therefore, not to be wondered at that the 
operation was imsuccessful. 

On physical examination the patient shows a good deal of 
pathology in his right chest. There is dulness in the right chest 
about the sixth rib posteriorly, running down to about the ninth 
rib. In front the signs are less pronounced. Very close to the 
sternum in front there is some hyperresonance, which is apt to 
be present when lung tissue is compressed. The breath-sounds 
are reduced over this area in front, also over the area posteriorly. 
RAles arc present over the posterior portion of the thorax in the 
dull area, and seem to be due to disturbance in the lung tissue. 



CLINICAL TALKS ON DIAGNOSIS 893 

On account of this area of dulness associated with rales and 
evidences of compression of the adjacent lung tissue suspicion 
of a neoplasm in the mediastinum was entertained. An a:-ray 
was taken and the ic-ray shows here. Although the umbilicus 
is not marked in this plate, it would be at this point [indicating]. 
Here is the diaphragm. Here is the area of greatest dulness, 
which is for the most part located at the angle between the right 
upper surface of the diaphragm and the spinal column. You 
will notice that the outline is not sharply demarcated, as it 
should be in a case of aneurysm. At this point the lung tissue 
is perfectly normal. On the left side the lung seems entirely 
normal. On the right side there is at the lower part of the lung 
a Httle biting out, and a mass, which you will see. You will 
notice that the upper part of the diaphragm is not sharply de- 
marcated along the sternum. You will also notice that this 
tumor mass extends from the fifth rib to the eighth rib. 

The first question is, is the tumor associated with the heart 
or with an aneurysm of the aorta? That it is not associated with 
the heart is perfectly clear by the examination of the latter organ, 
which by auscultation is found to be perfectly normal. More- 
over, there are no variations from normal on the part of the pulse. 
The argument against its being an aneurysm is the fact that the 
outhne, though fairly sharp, is not perfectly so, especially along 
the upper edge. In support of its being an aneurysm, you can 
count the pulsations of the heart by observing the movements of 
the right nipple and also by observing the wall of the axilla. On 
observing these facts more carefully it will, however, be noted 
that these movements are communicated movements and are 
not due to any expansile pulsations situated in the right chest. 
Moreover, there is no systolic murmur to be found. With 
aneurysm you would expect in more than half of the cases to find 
a systolic murmur. In very many cases of aneurysm diastolic 
shock is present, but in this case no diastolic shock can be pal- 
pated. You may reason also that this thing is not an aneurysm 
because there is no aortic insufficiency and because there is no 
specific history. 

Disease of the esophagus is not likely because there is no 



896 CLINICS OF JOHN B. MURPHY 

man's heart, the absence of any accentuation of the puhnonic 
second, and the complete absence of any trace of cyanosis, show 
that there is no pneumonia there. The diminution of the re- 
spiratory sounds over a puhnonary area, when accompanied by 
hyperresonance (Skodaic) on percussion, indicates a focus of re- 
laxed lung tissue — atelectasis. This condition may be due not 
only to pneumonia, but to any pathologic process which pro- 
duces pressure on the lung. If we could look this patient over 
with a fluoroscope, we might have some more light thrown on the 
nature of this round area of increased density which the a:-ray 
plate shows us in the right lower chest. There is a slight lateral 
deviation in the spine, the convexity to the left side. This is a 
fixed deviation and lies on a level with the tumor seen in the x-ray 
plate. [Addressing the patient.] How much pain have you 
in the side? Show me just where it is. [The patient points.] 
The cutaneous area which the patient indicates as the site of his 
pain corresponds exactly with the distribution of the intercostal 
nerves lying on a level with the tumor. It is quite possible that 
they may be nerve-root pains. What kind of a pain was it? 

Patient: At first it was a full pain (a distressing sense of 
fulness) ; then it became more severe. 

Dr. Murphy : You never had to have a hypodermic because 
of the severity of the pain? 

Patient: No. 

Dr. Murphy: All the diagnostic points which we have 
elicited would fit in with a sarcoma occurring in that position. 
There is, first, the circumscribed area of Skodaic resonance to the 
right of the vertebral column, which we elicited before the ic-ray 
plate was made. You see its location corresponds exactly with 
the mass seen in the a;-ray plate. Then there are the diminished 
respiratory sounds over this same area. Then there are the 
spitting-up of blood, the nerve-root pains, and the deviation of 
the spinal column. Finally, our diagnosis of an intrathoracic 
tumor compressing the lung and likewise involving the spinal 
column is confirmed by the radiogram. The outline of the lower 
right costal arch is slightly bulged outward and the ribs may be 
somewhat eroded, otherwise it would not hurt him so much to 



CLINICAL TALKS ON DIAGNOSIS 897 

press on his costal cartilages. That this man has an intra- 
thoracic neoplasm is certain, and that this neoplasm is the cause 
of the symptoms on account of which his gall-bladder was opened 
and for which he seeks relief from us is equally certain. Not 
infrequently cases of herpes zoster, which have prodromal rad- 
iating pains very closely similar to those of this patient, are 
operated under the diagnosis of acute cholecystitis or acute ap- 
pendicitis. Such errors are made not only during the prodromal, 
preeruptive stage of the disease, but also even in the presence of 
a florid eruption. Why? Perhaps because patients, particularly 
those with abdominal complaints, are examined too often in the 
prone position and doctors forget that these patients have backs, 
where zoster lesions are most frequently found. Just what is the 
nature of the tumor is far from certain, however. We should like 
to have a fluoroscopic examination made of this chest, because 
the fluoroscope will tell us whether or not this is a pulsating 
tumor. It it does not pulsate, we can rule out aneurysm with a 
fair degree of certainty. Of course, a very vascular tumor might 
also pulsate; so, in case we find pulsation present, we shall still 
remain somewhat in doubt. In general, however, when a tho- 
racic aneurysm produces hemoptysis it is very close to rupture, 
whereas a malignant tumor of the lung may produce hemoptysis 
relatively early in its course. Unless some new and unexpected 
developments occur in this case in the future, we shall consider 
it in all probability a sarcoma, going out most likely from the 
spinal column. Without the x-ray picture we might have been 
inclined to regard this case as a beginning spondylitis deformans 
because of the neuralgic pains, the slight lateral deviation and 
fixation of the spinal column, and the radiating pains on fist 
percussion. Metastatic spondyhtis is a fairly frequent condi- 
tion in the locality of Chicago; it is ahnost equally frequently 
overlooked by the surgeon; and the number of these cases that 
are operated for chronic appendicitis, cholelithiasis, gastric and 
duodenal ulcer, is not small. There is often a good deal of ex- 
cuse for the error. The signs and symptoms are often slight and 
misleading, and the x-ray plates, to detect with certainty the 
early cases, must be made by an expert. If at the present stage 
VOL. m— 57 



898 CLINICS OF JOHN B. MURPHY 

of this patient's disease we are having so much trouble trjdng 
to find out what is the matter with him, how much more diffi- 
cult it must be to diagnose such a case in the early days of his ill- 
ness? We have no criticism to make of the mistaken diagnosis 
of the surgeon who operated him for a gall-bladder lesion. 

A metastatic spondylitis is one of the things that must be 
looked for in every case of beginning or advanced fixation of the 
spine. Every fall and winter, from November to March, we get 
a group of these spondyhtis cases. They are primarily metastatic 
infections of the spine, the intervertebral articulations being in- 
volved. They occur in the farming districts at the season of the 
year when the people are husking com, digging potatoes, carry- 
ing grain, or doing other heavy work in the cold or wet. They 
work in stooped positions in the fields in damp weather, strain 
their backs, and also catch cold. The microorganisms from the 
throat or nose infection enter the blood-stream and are arrested 
in the neighborhood of the intervertebral articulations, producing 
an intervertebral arthritis. In consequence of these frequently 
recurring or chronic arthri tides, bony "Hpping" of the joint 
edges gradually occurs, and ends in complete bony fixation of the 
spine. It is difficult early to differentiate such an acute spondy- 
litis from an appendicitis or from a gall-bladder infection; but 
the fixation of the spine is practically always present in some de- 
gree in these cases, and particularly characteristic of this type of 
fixation is the fact that the spine is fixed over a considerable area, 
which may, and frequently does, include the entire column. It 
is a diffuse, not a sharply limited, focal process, and when it 
leads to the production of spinal deformity that deformity takes 
the form of a gradual curve. There is never any such angular de- 
formity in these cases as is seen in focal processes, such as tuber- 
culosis or metastatic carcinoma. 

[Note. — The patient left the hospital on May 23, 1914, his 
condition remaining practically unchanged except that the pain 
was diminished somewhat by the a:-ray treatments, given about 
every third day, using a rather hard tube. 

He continued frequently to cough up blood during his stay 
in the hospital, and this condition appeared to become worse as 



CLINICAL TALKS ON DIAGNOSIS 899 

time passed. He gradually became considerably worse after 
returning home, and he died early in September, 19 14. — Ed.] 



A TALK ON THE DIAGNOSIS OF MENINGITIS AND 
THE DIFFERENTIATION OF ITS VARIETIES BY DR. 
CHARLES L. MIX, ILLUSTRATED BY TWO CASES 

Dr. Mix (May 8, 1914) : The first patient I wish to show 
entered the hospital April 30, 19 14, in the service of another 
physician. The patient is an Italian, a young boy of about 
nineteen, utterly unable to imderstand or to speak English. We 
know nothing about his medical history except what we have 
been able to learn from friends who have called to see him. We 
understand that he was recently taken sick with some sort of 
fever, that he had headache and vomiting, and that he was un- 
able to do any more work on the railroad which employed him. 
He was, therefore, brought to the hospital and placed in a ward. 
Examination of the blood made May ist, showed that he had 
7600 leukocytes. A Widal reaction made the same day proved 
negative. An examination of his blood made again on the fifth 
of May showed 14,000 leukocytes. The urine showed no al- 
bumin, no sugar, an occasional hyaline cast, a few white blood- 
cells, and amorphous urates. 

You will observe that the patient is lying with his feet drawn 
up, so that the thighs are flexed upon the trunk and the calves 
upon the thighs. You will notice that if his legs are straightened 
that he shortly brings them back to the contracted state, evi- 
dently because this posture affords the greatest relief. You will 
notice that there is no retraction of the head. 

I wish first to call your attention to the history sheet of this 
patient. He entered at 8 p. m. on the thirtieth of April, coming 
in an ambulance. At the time of his admission his pulse was 80, 
his temperature 98.6° F., his respiration 18, a set of findings 
which apparently indicated no acute illness. The nurse records 
that at midnight his pulse was 66, his temperature 99.2° F., his 
respiration 26. He was very restless, and about i o'clock in the 
morning vomited some fluid of a greenish color. At 3 o'clock 



898 CLINICS OF JOHN B. MURPHY 

of this patient^s disease we are having so much trouble trying 
to find out what is the matter with him, how much more diffi- 
cult it must be to diagnose such a case in the early days of his ill- 
ness? We have no criticism to make of the mistaken diagnosis 
of the surgeon who operated him for a gall-bladder lesion. 

A metastatic spondyUtis is one of the things that must be 
looked for in every case of beginning or advanced fixation of the 
spine. Every fall and winter, from November to March, we get 
a group of these spondylitis cases. They are primarily metastatic 
infections of the spine, the intervertebral articulations being in- 
volved. They occur in the farming districts at the season of the 
year when the people are husking com, digging potatoes, carry- 
ing grain, or doing other heavy work in the cold or wet. They 
work in stooped positions in the fields in damp weather, strain 
their backs, and also catch cold. The microorganisms from the 
throat or nose infection enter the blood-stream and are arrested 
in the neighborhood of the intervertebral articulations, producing 
an intervertebral arthritis. In consequence of these frequently 
recurring or chronic arthritides, bony ** lipping" of the joint 
edges gradually occurs, and ends in complete bony fixation of the 
spine. It is difficult early to differentiate such an acute spondy- 
litis from an appendicitis or from a gall-bladder infection; but 
the fixation of the spine is practically always present in some de- 
gree in these cases, and particularly characteristic of this type of 
fixation is the fact that the spine is fixed over a considerable area, 
which may, and frequently does, include the entire column. It 
is a diffuse, not a sharply limited, focal process, and when it 
leads to the production of spinal deformity that deformity takes 
the form of a gradual curve. There is never any such angular de- 
formity in these cases as is seen in focal processes, such as tuber- 
culosis or metastatic carcinoma. 

[Note. — The patient left the hospital on May 23, 19 14, his 
condition remaining practically unchanged except that the pain 
was diminished somewhat by the jc-ray treatments, given about 
every third day, using a rather hard tube. 

He continued frequently to cough up blood during his stay 
in the hospital, and this condition appeared to become worse as 



CLINICAL TALKS ON DIAGNOSIS 899 

time passed. He gradually became considerably worse after 
returning home, and he died early in September, 19 14. — Ed.] 



A TALK ON THE DIAGNOSIS OF MENINGITIS AND 
THE DIFFERENTIATION OF ITS VARIETIES BY DR. 
CHARLES L. MIX, ILLUSTRATED BY TWO CASES 

Dr. Mix (May 8, 1914): The first patient I wish to show 
entered the hospital April 30, 1914, in the service of another 
physician. The patient is an ItaHan, a yoimg boy of about 
nineteen, utterly unable to understand or to speak English. We 
know nothing about his medical history except what we have 
been able to learn from friends who have called to see him. We 
imderstand that he was recently taken sick with some sort of 
fever, that he had headache and vomiting, and that he was un- 
able to do any more work on the railroad which employed him. 
He was, therefore, brought to the hospital and placed in a ward. 
Examination of the blood made May ist, showed that he had 
7600 leukocytes. A Widal reaction made the same day proved 
negative. An examination of his blood made again on the fifth 
of May showed 14,000 leukocytes. The urine showed no al- 
bumin, no sugar, an occasional hyaline cast, a few white blood- 
cells, and amorphous urates. 

You will observe that the patient is lying with his feet drawn 
up, so that the thighs are flexed upon the trunk and the calves 
upon the thighs. You will notice that if his legs are straightened 
that he shortly brings them back to the contracted state, evi- 
dently because this posture affords the greatest relief. You will 
notice that there is no retraction of the head. 

I wish first to call your attention to the history sheet of this 
patient. He entered at 8 p. m. on the thirtieth of April, coming 
in an ambulance. At the time of his admission his pulse was 80, 
his temperature 98.6° F., his respiration 18, a set of findings 
which apparently indicated no acute illness. The nurse records 
that at midnight his pulse was 66, his temperature 99.2° P., his 
respiration 26. He was very restless, and about i o'clock in the 
morning vomited some fluid of a greenish color. At 3 o'clock 



900 



CLINICS OF JOHN B. MURPHY 



he was sleeping. At 4 in the morning he passed 270 c.c. of urine. 
The nurse records that he had a poor night and that he slept but 
four hours. At 6 o'clock in the morning his pulse was 51, his 
temperature 98° F., his respiration 18. At 8 o'clock his pulse 
was 70, his temperature 98.4° F., his respiration 20. At 10 
o'clock he again vomited. At 3 p. M. his pulse was 60, his temper- 
ature 98.6° F., his respiration 20. He again vomited. At 6 p.m. 
his pulse was 62, his temperature 98.4° F., his respiration 18. 
At 10 p. M. his pulse was 52, his temperature 98.4° F., his respira- 
tion 22. At midnight his pulse was 50, his temperature 99.4° 
F., his respiration 22. I have given a summary of this first day 
in the hospital because upon that day, by reason of this record, 
we had no difficulty in making our diagnosis. We then had 
sufficient data, and sufficient data have already been given to 
you to make a tentative diagnosis. There are in thiL case four 
very important elements — headache, vomiting, a very slow 
pulse, and some slight fever. 



Date 


Pulse 


Temperature 


Respiration 


Febniarv ?'i, ■? a, \r. 


88 
86 
60 
74 
56 
64 

84 
88 
66 
64 
64 
88 
80 


101.2° F. 
100.2° F. 

99.2'' F. 

99.6 F. 

99.2° F. 

98.6° F. 

100.0° F. 
100.2° F. 
100.6° F. 
100.0° F. 

99.8° F. 
101.0° F. 

99.0° F. 


22 


6 A. M 


22 


A. M. . 


20 


12 M 


20 


^ p. M. . 


20 


6 P. M. 


20 


February 26, 3 a. >,f. 


22 


6 A. M 


24 
22 


A. M 


12 M 


20 


1 p. M 


23 


6 p. M 


24 

22 


p. M 







Before saying anything further about this present case, I 
wish to call your attention to that of another patient who entered 
the hospital on the twenty-fourth day of February, and who died 
on the twelfth of March. This man when he entered was ap- 
parently in excellent condition. He entered at 6 p. M. on the 
twenty-fourth of February, walking into the ward complaining 
merely of pain in his head and of vomiting. He also had pain in 



CLINICAL TALKS ON DIAGNOSIS 90I 

his back, extending around to his abdomen. At 6 p. m. his pulse 
was 80, his temperature 101.8° F., his respiration 24. At 9 p.m. 
his pulse was 86, his temperature 102.6° F., his respiration 24. 
At midnight his pulse was 88, his temperature 101.4° F., his respi- 
ration 24. The following table shows his pulse and temperature 
rates during the next two days . 

Why have I taken the pains to transcribe this record upon 
the blackboard? Simply because this record carries with it the 
diagnosis. There is only one acute condition which can cause 
such a pecuUar relationship between pulse-rate and temperature, 
and such a pecuHar oscillation of pulse-rate and temperature, 
and that disease is meningitis, whether of the tuberculous, of the 
epidemic, or of the pneumococcic variety. In the early stage of 
the disease the pressure of the fluid exudate is considerable. 
There is a marked irritation of the pneumogastric inhibitory 
fibers, with the result that the pulse-rate is remarkably slow. 
In the case of this man whose temperature record has been trans- 
cribed, only four symptoms were ever presented. These are: 
slow pulse, variable temperature, headache, and vomiting. Upon 
these four signs and symptoms the diagnosis of meningitis was 
tentatively made and a lumbar puncture done. The result of 
the lumbar puncture was that a perfectly clear fluid was ob- 
tained, which on microscopic examination showed no bacteria 
and hardly more than the ordinary number of lymphocytes after 
vigorous centrifuging. The cerebrospinal fluid, however, was 
found to be under tension when the lumbar puncture was made. 
I had a guinea-pig injected with this cerebrospinal fluid on the 
third of March, 19 14, and the guinea-pig died on the fourteenth 
day of April, just forty-two days after the injection. The post- 
mortem on the guinea-pig made by Professor F. Robert Zeit, 
of Northwestern University Medical School, showed enlarged 
caseous inguinal glands and a miliary tuberculosis of the spleen. 
Tubercle bacilli were found in the smears from both the inguinal 
glands and the spleen. Meanwhile the patient himself had died 
on the twelfth day of March, showing no further symptomatology 
than the development of semi-coma and then of coma. After 
the liunbar puncture was made the man made quite an improve- 



902 



CLINICS OF JOHN B. MURPHY 



ment, so that one of the visiting physicians jokingly told me that 
my tuberculous meningitis case was getting well. I told him to 
wait and see. 

Whenever you run upon a case without labial cold sores, 
with an insidious onset, with the presence of headache of a severe 
and continuous type, with vomiting not to be explained on the 
basis of any disturbance of the alimentary canal, with a pulse in 
the fifties, and a temperature above normal, it is always your 
duty to bear constantly in mind the possibiHty of tuberculous 
meningitis. It is always your duty to do a Imnbar puncture in 
these suspected cases, and, furthermore, to inoculate a guinea- 
pig with one or two cubic centimeters of the cerebrospinal fluid. 

Returning now to the patient whom we are at present con- 
sidering, I would like to call your attention to his temperature 
range on the second, third, and fourth of May. 



Date 


Pulse 


Temperature 


Respiration 


May 5, 6 A. M 


54 
50 
54 
54 
60 

54 
56 

Sleeping 
46 
54 
52 
60 
52 
80 
66 

78 
68 
60 
72 
68 
72 


98.2° F. 
97.8** F. 
98.0" F. 
100.2° F. 
98.6° F. 
99.0° F. 
99.0° F. 

98.6° F. 
97.8'' F. 
97.6° F. 
99.6: F. 

99-< I- 
loi.o F. 

99.0° F. 

100.4'' F. 

99.6" F. 

98.8° F. 
100.0° F. 

99.6° F. 

99.2° F. 


22 


A. M 


22 


12 M 


20 


^ P. M 


20 


6 P. M 


20 


P. M 


20 


12 P. M 


22 


May ^. •? A. M 




6 A. M 


20 


A. M 


20 


12 M 


20 


2 P. M 


24 
26 


6 P. M 


Q P. M 


26 


12 P. M 


22 


May 4, 6 A. M 


20 


A. M 


20 


12 M 


22 


« P. M 


22 


6 P. 11 


20 


P. M 


28 







You will notice the great similarity between this set of pulse- 
rates and temperatures and the case of the man whom I just 
mentioned, whose death, together with that of the guinea-pig. 



CLINICAL TALKS ON DLA.GNOSIS 903 

proved the presence of tuberculous meningitis. So closely 
similar were these history sheets that the intern recognized at 
once that the cases were identical in type. 

On the second of May the young Italian slept a great deal of 
the time and in the late afternoon complained of soreness and 
aching in his neck and shoulders. In the night he tried to get 
out of his bed, being apparently somewhat irrational. During 
most of the forenoon of the third of May he slept. About noon- 
time he began picking at his face and nose in an apparently aim- 
less manner, his temperature at this time being one degree sub- 
normal. It was on this day that I was first called to see him and 
did the lumbar puncture At that time he seemed somewhat 
irrational, but, of course, his inability to speak Enghsh and my 
inability to speak Italian made conversation rather difficult. The 
nurse reports that during the night he was again very restless. 
On the morning of the fourth the nurse noted that he was irra- 
tional all the forenoon, and in the afternoon apparently did not 
recognize anybody. On the fifth of May for the first time he 
began having involuntaries. During this day he began to moan 
in his sleep and his limbs twitched. The nurse reports that dur- 
ing the forenoon of the fifth he was apparently unconscious. He 
remained unconscious, or at least semi-unconscious, with in- 
voluntaries during the day of the sixth, until late at night, when 
he tried to talk a little. 

On the fifth of May a marked change took place in his pulse- 
rate. At 3 A. M. it was 78; at 12 M. it was 78; at 3 p. m. 96, at 
9 p. M. no. On the sixth of May it was no at i A. M., 128 at 6 
A. M., 1 18 at 8 A. M., 1 1 2 at noon, and 120 the rest of the day. On 
the seventh his pulse varied between 104 and 150. This ex- 
treme variation took place within three hours' time. At 3 A. M. 
his pulse was 112; at 6 a. m., 148; at 9 A. m., 126; at noon, 124; 
at 3 p. M. 150, with a temperature of 100.6° F.; at 6 p. m. 104, 
with a temperature of 100° F.; at 9 p. M. 128, with a tempera- 
ture of 99.6° F.; at midnight 138, with a temperature of 99.8° F. 
This morning his pulse is 112 and his temperature 98.8° F. 

Yesterday morning early he was pulling at the covers with- 
out apparently knowing what he was doing, but at 9 o'clock he 



904 CLINICS OF JOHN B. MURPHY 

became conscious and tried to talk and moved his hands and 
legs about with some show of reason. He was conscious all yes- 
terday afternoon, though during the night he talked and moaned 
a good deal. This morning he has been quite rational and is 
rational at the present time. Notwithstanding the fact that he 
is at the present rational, he had this morning involuntary 
passages of urine as usual. 

Physical examination in this young man's case shows, be- 
sides this remarkable relationship between pulse and temperature, 
a few facts which are rather characteristic of meningitis. First 
of all he assumes a posture in bed which is assumed by most 
patients suffering from this disease. His neck and head are 
not retracted, it is true, neither are they stiff, as you can see, 
when I attempt to lift his head, but you will notice, as I said 
before, that his feet and his legs are drawn up, his thighs being 
flexed on the abdomen and the calves on the thighs. You will 
notice also that when I touch him he is apparently hurt by the 
touch. That is to say, he resents the touch and moans when his 
limbs are changed in their position. 

You will notice further that Kernig's sign is present; that is 
to say, when his thighs are flexed upon his abdomen, the legs 
cannot be forcibly extended. This is because of the con- 
tracture which is taking place in his hamstring muscles. This 
contraction is an evidence of cerebrospinal meningitis. It is by 
no means confined to the semimembranosus, semitendinosus, 
and biceps femoris muscles. It is found all over the body. Ker- 
nig's sign is of importance not so much in itself as in proving 
the presence of a hypertonic state of the muscles of the body. 
The muscles of the tnmk share in this hypertonic state and the 
retraction of the head and neck, so commonly a picture in men- 
ingitis, is to the muscles of the back what Kernig's sign is to the 
hamstring muscles, namely, a sign of increased muscle tonus. 
The arms also show this same phenomenon. You will notice 
that the forearms are flexed upon the arm. When I try to 
straighten them, the patient moans slightly and is apparently 
caused some pain. The reason is that we have a hypertonic 
state in the biceps cubiti which must be overcome if the arm is 



CLINICAL TALKS ON DLA.GNOSIS 905 

to be extended; and overcoming this hypertonus causes pain. 
Sometimes hypertonus of the erector spinas muscles causes in 
some cases a condition of opisthotonos of mild degree. 

You will notice that the patient also shows marked sensitive- 
ness of the skin. Leube long since called attention to the hy- 
peresthesia of the skin and muscles in meningitis. Personally I 
regard it as one of the most characteristic features of the disease. 
To me Kernig's sign is no more valuable a diagnostic point than 
the hypersensitiveness which is present in the patient's body dur- 
ing the progress of the meningitis. 

Turning now to another set of phenomena which makes the 
diagnosis of these cases most certain, we will look at the boy's 
pupils. You will notice that the left pupil is larger than the 
right. This inequality is very variable, as is also the size of the 
pupils. In the early stages of meningitis the pupils are very apt 
to be contracted. Later on they become dilated, but usually 
imequally, so that one pupil may be mydriatic while the other 
is normal in diameter. The variability of the pupils rather than 
the mere presence of inequality is the important fact. You may 
find one pupil widely dilated in one hour and perhaps the next 
hour find it of normal size. 

In these cases the muscles of the eyeballs are frequently in- 
volved, and a very common finding is ptosis of one or the other of 
the levator palpebrae superioris muscles. Frequently there is a 
strabismus, quite as often due to the paresis of the internal rectus 
as of the external rectus. We find, therefore, that the eyeball 
may sometimes turn in or sometimes may turn out. In this boy's 
case there has been previously a paresis of both of the internal 
recti muscles, though there is nothing to be seen at the present 
time. 

Summarizing his symptomatology, we have the remarkable 
pulse and temperature relationship — a very slow pulse in the 
early stages, the presence of severe headache with vomiting; 
the presence of pupillary inequality and variability in the size, 
with transitory internal strabismus. We need no further data 
to make a diagnosis of meningitis, but we do need further data 
in order to determine the type of meningitis present — whether 



go6 CLINICS OF JOHN B. MURPHY 

it is of the tuberculous or epidemic variety. Is it a streptococcic 
meningitis? Is it one of those rarer forms due to the typhoid 
fever bacillus, the influenza bacillus, the staphylococcus, or the 
pneiunococcus? These questions can be answered very quickly 
if we have recourse to a lumbar puncture. It goes without saying 
that the first time we saw this patient we had recourse to a 
lumbar puncture. We obtained a fluid which was apparently 
perfectly clear to the naked eye, but which on centrifuging 
showed more than the very few lymphocytes obtained in centri- 
fuging normal cerebrospinal fluid. We have injected into a 
guinea-pig one cubic centimeter of the cerebrospinal fluid. This 
we did on May 4th. We expect the guinea-pig to die of tuber- 
culosis.* We expect him to die of tuberculosis because the 
cerebrospinal fluid was clear. Had any of the germs which have 
been above mentioned been the cause of the meningitis we should 
have found numerous polymorphonuclear cells in the fluid, and 
a test-tube of it would have given the appearance of ground-glass 
or an almost opaque fluid, varying from a haze to a complete 
opacity. On one occasion on doing a lumbar puncture I actually 
withdrew pus from the cerebrospinal canal due to a staphylococcic 
meningitis, from which the patient died on the following day, 
the case up to that time having been regarded as typhoid fever, 
though no Widal had been present. 

The fluid in the case of this young man came out with a good 
deal of rapidity, indicating quite a bit of tension. Often after 
such a lumbar puncture the patient is better, but no improve- 
ment followed in the case of this individual. 

Another reason why we say this case is a tuberculous men- 
ingitis rather than a meningitis caused by some other bacterium 
is because of the absence of herpes and of signs of infection of any 
sort elsewhere in the body. Many cases of meningitis have their 

* The guinea-pig was injected on May 4th with one cubic centimeter of cere- 
brospinal fluid. This guinea-pig died on June 12, 1914, thirty-nine days later. 
Most guinea-pigs die on the fortieth day when injected with fluid which contains 
tubercle bacilli. This guinea-pig died on the thirty-ninth day, thus j)roving tlu- 
rule. The postmortem on the guinea-pig was performed by I'rofessor V. Robert 
Zcit, Professor of Pathology, Northwestern University Medical S( h(K)l. It showed : 
I. Tuberculous peritonitis. 2. Miliary tuberculosis of spleen and liver. 3. Tu- 
berculous lymphadenitis of the inguinal and mediastinal glands. 



CLINICAL TALKS ON DIAGNOSIS 907 

etiology indicated by disease elsewhere, so that it is a very simple 
thing to arrive at a diagnosis. Thus in typhoid fever the signs 
of meningitis confirmed by a lumbar puncture point clearly to 
the typhoid bacillus as the cause. This cause, however, is ex- 
tremely rare, Ohlmacher having reported originally a series of 
12 cases only. On the other hand, if the individual is suffering 
from abscess of the middle ear due to some form of streptococcus, 
one has no difficulty in diagnosing the meningitis when it de- 
velops and in being positive as to the germ causing the meningitis. 

This is a case of meningitis which developed out of a clear 
sky and which must be one of four sorts — either tuberculous, 
epidemic, influenzal, or pneimiococcic. Tuberculous meningitis 
is insidious in its onset, is usually associated with slow pulse, and 
is much more apt to have convulsions than the other three forms. 
The pneumococcic variety is almost invariably associated with 
severe cold sores. The influenzal type occurs only during epi- 
demics of influenza, and is usually associated with evidences of 
influenza of an incipient type. The epidemic variety, like the 
pneimiococcic, is usually associated with cold sores, so that the 
facial appearance of the two is very much the same. Indeed, 
so closely may these two types resemble each other that the dif- 
ferentiation may be impossible except by the examination of the 
cerebrospinal fluid or by a blood culture. 

The leukocyte count helps very much in the differentiation 
of the tuberculous forms from the streptococcic, epidemic, in- 
fluenzal, and pneumococcic varieties. All four of the latter 
have very high leukocyte counts, especially the epidemic form. 
The leukocyte count in the tuberculous form is either normal 
or slightly above normal, being in the case of this young Italian 
7600 on the first of May and 14,200 on the fifth. In the case of 
the man whose temperatures I gave you at first and who died 
from a tuberculous meningitis on the twelfth of March the blood 
count on the twenty-fifth of February was 8600 leukocytes, and 
on the twenty-eighth of February 8000 leukocytes. 



908 CLINICS OF JOHN B. MURPHY 

PNEUMOCOCCUS MENTNGITIS 

The next patient is a married woman who entered the hos- 
pital with the following history: 

(Intern reads history.) 

Patient, female, aged twenty-three, married, was brought to 
the hospital Friday evening, May i, 19 14. Her past history is 
negative. Her mother died three years ago from an injury re- 
sulting from a fall. Father is living and well. She has six 
sisters and three brothers living and well. Her husband is Uving 
and well. 

Menstruation began at the age of fifteen, regular, twenty- 
eight-day type, three or four days' duration, four napkins a day, 
with little pain. She has had no children and no miscarriages. 
Her last period was in September, 1913, and she is seven months' 
pregnant. 

Her present illness dates back to April 25th. Her husband 
states that when he returned from work the patient complained 
of a severe frontal headache, which had come on suddenly that 
afternoon. On Sunday morning, April 26th, about 9 a. m., she 
vomited for the first time. The vomiting was projectile in type 
and had no relation to eating. She was not nauseated. A doc- 
tor was called who said she had the grip, for which he gave her 
some medicine. The headache continued on the twenty-sixth, 
twenty-seventh, twenty-eighth, and twenty-ninth of April. She 
also vomited many times during these four days, and it was 
always projectile in type. On Wednesday morning the head- 
ache became occipital and was still intense in character. She 
did not vomit after Thursday morning, but the headache con- 
tinued. 

She has had no cough and no pain, excepting the headache. 
She had a slight backache in the lumbar region on Sunday morn- 
ing, but this lasted only a short time. On Thursday night she 
felt much better and slept well. On Friday morning her hus- 
band says that she had a temperature for the first time, and on 
that afternoon became unconscious. 

Dr. Mix: You will notice in the history which has just been 



CLINICAL TALKS ON DLVGNOSIS 909 

read that the patient's trouble began rather abruptly with head- 
ache on the twenty-fifth of April. Sunday morning, April 26th, 
a few hours after the onset of the headache, she vomited and the 
vomiting was projectile in type. The headache and vomiting 
continued until the time when she entered the hospital; and the 
vomiting, you will notice, was always projectile. Were no other 
statements made one might suppose that the patient was suffer- 
ing from a cerebral tumor and one might, with every reason in 
the world, conclude that she was at least suffering from an in- 
creased intracranial pressure from some cause, inflammatory 
or neoplasmic. The history states that there was no cough or 
pain. There was, however, a slight backache on Sunday morn- 
ing in the lower part of the spine. Her husband notes that the 
temperature appeared for the first time on Friday morning, that 
is, almost a week after she was taken ill. We believe this to be 
a mistaken observation. Probably by Friday the fever be- 
came so high that it for the first time impressed him. On the 
afternoon of Friday the husband states that his wife became 
unconscious. 

Let me first call your attention to the history sheet which 
this patient shows. The leukocyte count made on the second 
of May showed 28,600; a second, made on the fourth, showed 
21,800. The patient entered the hospital at 10 p. m. on the night 
of the first of May, coming in an ambulance, her pulse being 104, 
her temperature 100° F., her respiration 28. During the night 
she had in voluntaries. There was severe hiccup, lasting fifteen 
minutes, and the patient tried repeatedly to get out of bed. 
She was dehrious or semi-comatose all night. The following 
morning, on the second of May, she dozed and slept some and 
was quite rational at times, her pulse falling from 112 to 100, her 
temperature being 98.4° F., the forepart of the day, but rising to 
102° F. at midnight. At 9 p. m. of the second of May her pulse 
was 102; at midnight, 130. At 3 A. m. on the third her pulse was 
160; at 6 A. M. it was still 160; at 9 a. m. it dropped back to 104. 
During the third she had some slight nose-bleeding in the after- 
noon, was restless all the day, and had involuntaries. On the 
fourth of May her pulse was remarkably better, being 102 at 



9IO CLINICS OF JOHN B. MURPHY 

3 A.M.; io6at6A. M.; ii6at9A. m.; 98 at noon; 100 at 3 p.m.; 
106 at 6 p. M.; 104 at 9 p. M.; 100 at midnight. During that 
day she rested fairly quietly and spent a good night. The fol- 
lowing day, the fifth of May, her respiration varied from 22 to 
34, and her pulse from 90 to 130; her temperature from 98° to 
103.4° F. On the sixth of May her pulse varied from 88 to 116, 
her temperature from 98.4° to 102.6° F. She was somewhat 
restless, but on the whole passed a fairly good day. Yesterday, 
the seventh, her pulse range was from 100 to 120. The nurse 
notes that she had a fair day. 

This morning, at 3 A. M., her pulse was 96, her temperature 
99° F., and her respiration 26. At this time she had a slight chill 
which lasted four minutes. A short time after that there was a 
gush of blood from the vagina and she was delivered of a three- 
pound baby at 4.20 this morning. (The baby lived only thirty- 
six hours.) The placenta was delivered intact at 4.30. This 
morning, at 9 A. m., her pulse was 104, temperature 97° F., res- 
piration 24. She has slept quietly and seems in fairly good con- 
dition. 

I wish to call your attention to the symptoms which this pa- 
tient shows. First of all, you will note upon her lips a large num- 
ber of cold sores. Indeed, these cold sores carry with them the 
diagnosis, and when I first saw this patient, noting the cold sores 
and reading the history and seeing the temperature chart, I 
could not help but feel that a pneumococcic infection was present. 
To be sure, an epidemic cerebrospinal meningitis case might 
present the same sort of a picture, but the cold sores were so very 
like the cold sores of an ordinary pneumococcic case that when 
I first glanced at the patient before looking at her history I men- 
tally wondered whether she was not suffering from pneumonia. 
The first thing I did was to examine her chest and to prove to my 
own satisfaction that her lungs were perfectly normal. Indeed, 
her respiratory rate during most of the days that she has been in 
the hospital varied only between 22 and 34. You will note this 
morning on examination of the lungs that there are no areas of 
consolidation either in front or in the back. 

On examination of the heart there was to be found when I 



CLINICAL TALKS ON DIAGNOSIS 9 II 

first looked at the patient a systolic murmur from a mitral in- 
sufficiency. We have learned from her husband that this is an 
old lesion that she has had for a long time, and which dated from 
a previous rheumatic fever. The murmur which she has ap- 
parently has in no way been disturbed by her present illness. It 
is neither louder nor fainter than it has been at any time, and 
the heart is evidently in fair condition. 

Examination of the blood, which was made, showed that the 
leukocytosis was made up largely of polymorphonuclear cells. 
In the tuberculous variety the leukocyte count is usually normal 
or slightly above normal, seldom if ever rising as high as 20,000. 
In pneumococcic meningitis and in the epidemic, influenzal, and 
streptococcic varieties the blood count is always very high, the 
excess of corpuscles being made up of polymorphonuclear cells. 
In the tuberculous cases the eosinophils are either decreased or 
entirely absent. 

You will note that this patient also has Kernig's sign; that 
there is some hypersensitiveness of the skin; some stiffness and 
soreness of the muscles, and the same rigidity that was present 
in the case of the Italian boy suffering from a tuberculous men- 
ingitis. You will note further the presence of an extreme de- 
gree of vasomotor irritability in the shape of the so-called tdche 
cerebrate. It is not the red or white streak which appears after 
sweeping your finger over the skin which is important. It is 
the vasomotor irritability which this tdche cerehrale shows which 
is the important thing. This vasomotor irritability and vaso- 
motor paresis are of great diagnostic value in cerebrospinal 
meningitis. 

You will note the posture of this patient in bed is similar to 
that taken by the Italian Loy. You will notice, however, that 
there is more rigidity in the neck muscles than he showed. 

Passing to the abdomen, you will notice that the abdomen is 
not scaphoid, neither was there any scaphoidism in the case of 
the young Italian. It has been frequently said in text-books that 
a scaphoid abdomen is an extremely common thing in tuberculous 
meningitis, but that it is not apt to be present in the other forms. 
I have never been able to satisfy myself as to the truth of this 



912 CLINICS OF JOHN B. MURPHY 

Statement. A scaphoid abdomen ordinarily means absorption of 
mesenteric fat, together with excessive rigidity of the anterior 
abdominal wall. This excessive rigidity is merely a part of the 
general rigidity uniformly present. So far as I have been able to 
observe, the cases which survive for some time all show the 
scaphoid abdomen, no matter what the type of meningitis. 
Those living only a short time will not show the scaphoid ab- 
domen. 

This patient has had no convulsions. Usually the pneumo- 
coccic cases are entirely free from convulsions. Osier, in his text- 
book, states that he has never seen a convulsion in the case of 
pneumococcic meningitis. The convulsions are more character- 
istic of the tuberculous type. They also occur, of course, in the 
epidemic cases. They are practically imknown in the pneim^io- 
coccic cases. 

I wish to call attention, furthermore, to the fact that this 
patient vomited a good deal at the beginning. I wish further to 
emphasize that the vomiting was of the projectile type, indicating 
increased intracranial pressure, undoubtedly from the products 
of the meningitis. Cerebral vomiting in the cases of meningitis 
is usually not associated with the presence of bile. These pa- 
tients take their nourishment fairly freely and yet vomit, the 
underlying cause of the vomiting not being due to disturbances 
of the stomach and intestines. When tuberculous or pneumo- 
coccic meningitis cases begin to vomit they do so until the 
stomach is entirely empty. If they get no more food there is 
vomiting usually merely of mucus and gastric juice. 

Very important in the examination of these cases is the mental 
state. All of them show interference with consciousness. De- 
lirium is usually early and sometimes very pronounced. It is 
the same type of delirium that is met with in typhoid fever. In 
typhoid fever there is often a condition of meningism, namely, a 
condition of toxicity of the cortex. The symptoms which it pro- 
duces in the nerves, blood-vessels, and various muscles of the 
body, subsultus tendinum, are the very same symptoms which 
are present in cases of meningitis. The delirium is usually of 
the quiet type, the patient fumbling about or trying to get out of 



CLINICAL TALKS ON DIAGNOSIS 913 

bed. Usually this delirium after a time passes over into coma 
with involuntaries, this coma ultimately giving place to death. 
Sometimes there is a severe convulsion followed by delirium, the 
delirium terminating n coma and the coma terminating in death. 
These are the usual stages of a long case of meningitis, whether 
of the tuberculous, epidemic, or pneumococcic variety. 

Further examination of the patient now before us discloses 
certain defects of the cranial nerves. You will note that there 
is inequaHty of the pupils; that there is, furthermore, a ptosis of 
the left eyelid, and that there is an internal strabismus. The 
facts which we have thus far brought out in regard to the case 
are convincing that meningitis is present, but thus far they are 
not convincing as to the type of meningitis. The cold sores 
present are certainly suggestive of the pneumococcus. The 
track of the pneumococcus is shown by the cold sores which it 
leaves behind it, and by its tracks you can often infer its presence. 
The blood culture which I ordered in the case of this patient at 
the same time that I made the lumbar puncture showed pneumo- 
cocci present. The Widal, previously ordered by the intern, 
was negative. Of course, in the presence of a leukocyte count 
of 28,600, made on May 2, a Widal test was entirely unnecessary, 
for no case of typhoid fever ever shows a leukocyte count of 
28,600. It was, however, ordered and made, and the result, of 
course, was negative. 

I made a lumbar puncture in this case the first day I saw the 
patient. We obtained a cerebrospinal fluid which was quite 
turbid by reason of the large number of polymorphonuclear cells 
which it contained. On examination of this cerebrospinal fluid 
pneumococci were found. There were no diplococci within the 
cells. The pneumococci were free in the fluid. We thus have 
in this case two reasons for believing that the patient has a 
pnemnococcic meningitis, namely, the positive blood culture 
of pneumococci and the finding of the same pneumococci in the 
cerebrospinal fluid after a lumbar puncture. 

I wish to call attention to one peculiar point in this patient's 
case. On the second of May, at 9 p. M., her pulse was 102; at 
midnight, 130; at 3 a. m., 160; at 6 A. m. it stifl remained 160; 
VOL. m— :;8 



914 CLINICS OF JOHN B. MURPHY 

but at 9 A. M. it dropped to 104. The patient entered the hos- 
pital about seven months pregnant. During all the time of her 
illness the fetal heart has been clearly heard, and this morning 
at 4.20 she gave birth to a seven months' baby which is still Uv- 
ing. The sudden increase of the pulse from 102 to 160 and its 
sudden fall to 104 is rather difficult of explanation. I believe, 
however, that it is due not to any disturbance of the pregnancy, 
because we know that no disturbance took place, but that it was 
rather caused by some disturbance of the cardiac inhibitory ap- 
paratus. There is in all cases of meningitis great irritabihty 
on the part of the inhibitory nerves from the vagus to the heart. 
In the early stages of meningitis, during the period of muscular 
irritability, rigidity, and hypertonus, there is also a marked irri- 
tability of the cardiac pneumogastric fibers. This is shown by 
the fact that the pulse-rate often runs as low as 50, as in the case 
of our Italian boy. I look upon this very slow pulse as being due 
to irritation (that is to say, stimulation) of the cardiac inhibitory 
center in the floor of the fourth ventricle, either because of direct 
pressure upon it from the increased pressure in the cerebro- 
spinal fluid or because of irritation by the toxins of the pneumo- 
cocci upon the cardiac inhibitory center. There is at any rate 
in the early stage a marked irritability of these cardiac fibers. 
The result of the increased irritation is a marked slowing of the 
pulse — ^just such a slowing as one might obtain by artificial stim- 
ulation of the cardiac inhibitory fibers of the pneumogastric. 
In this particular case of pnetunococcic meningitis the sudden 
acceleration of the pulse to 160 probably marked the stage in 
which the irritation of that apparatus, by reason of its great ex- 
cess, passed over into a stage of complete paralysis of that ap- 
paratus. The result would be that no more inhibition would 
take place and consequently the pulse would run the rapid and 
alarming rate of 160. The same thing happens previous to 
death in the tuberculous, pneumococcic, and epidemic cases of 
meningitis, and a very rapid pulse is almost invariably recorded 
in the last day or twelve hours of these patients' lives. The 
reason is that the toxicity of the blood has reached such a degree 
that the cardiac inhibitory apparatus is completely paralyzed; 



\ 



CLINICAL TALKS ON DIAGNOSIS 91$ 

and the paralysis is so deep that it is never recovered from and 
death follows within a few hours' time. Such was the case with 
the man with the tuberculous meningitis who died on the twelfth 
of March. His pulse on the eleventh was 106 at noon time; 108 
at 3 P.M.; 108 at 6 p. M. ; 1 1 2 at 9 p. m. At this time the patient 
began to be very restless, talked a good deal, and was perspir- 
ing freely. His pulse then went up to 140 at midnight; at 
2 A. M. 160, and thereafter the nurse was unable to count it at 
all. At 8.30 A. M. his respirations ceased. We have here again 
the same acceleration of the pulse before death that takes place 
in the great majority of these cases. I believe that death in 
practically all the cases of cerebrospinal fever is primarily due 
to a paralysis of the cardiac inhibitory fibers with secondary 
paralysis of respiration. 

Returning now to our case of pneimiococcic meningitis, I am 
going to do a lumbar puncture and then Dr. Murphy is going to 
speak about the treatment of these cases. The technic of a 
lumbar puncture is extremely simple. You merely find the 
crest of the ilium and draw a line across the back, midway from 
one crest to the other, locating the first spinous process above 
this imaginary fine with the finger. The skin is then painted 
with iodin. You then insert your needle, which should be two 
and three-fourths or three inches in length into the back, about 
one-fourth of an inch from the midHne, either to the right or the 
left of the spinous process. The needle is pointed in a direction 
upward very sHghtly and toward the midHne, at such an angle 
that the tip of the needle will be in the midHne when it is admitted 
to a depth of about one and one-half to two inches. When you 
insert your needle you will usually feel in the majority of instances 
the point coming in contact with the vertebral lamina. You 
then manipulate your needle, pointing it a Httle higher upward, 
so that it just skips the edge of the lamina. As the needle passes 
into the spinal canal you can distinctly feel it going into a hole, 
which it does very easily. You then release your finger from 
the needle end and the cerebrospinal fluid usually passes out at 
once. It often passes out under very great tension. 

The reason for doing a lumbar pimcture this morning is not 



9l6 CLINICS OF JOHN B. MURPHY 

for diagnostic purposes at all. It is a part of the treatment of 
these cases. These patients show a varying degree of somnolence 
and coma, depending upon the varying degrees of pressure; and 
the degree of pressure can be controlled by occasionally deplet- 
ing the cerebrospinal fluid by puncturing. Were this a case of 
epidemic cerebrospinal fever we would not only remove 20 to 30 
cubic centimeters or more of the cerebrospinal fluid, but we would 
also insert into the spinal canal a dose of Flexner's serum. This 
being a case of pneumococcic meningitis, we merely deplete the 
cerebrospinal fluid without inserting anything in its place. 

COMMENTS 

Dr. Murphy (May 8, 1914): Dr. Mix is puncturing the 
spine in this case as a therapeutic measure. The excess of intra- 
cranial and spinal pressure is making the patient comatose. By 
carrying out this simple procedure, we believe we are treating the 
case from a well-grounded surgical standpoint. Infection does 
its mischief through the tension imder which its products are 
held, in practically every variety of inflammation except the 
streptococcus infections. The streptococcus infections do not 
do much mischief, as a rule, through the tension under which the 
products of inflammation are held, because the streptococci run 
freely through the lymphatics, usually, are not held in loco, and, 
therefore, do not produce tense foci of pus; while staphylococci 
and pneumococci are held in situ by the resistance to their spread, 
and by the inflammatory coffer-damming of the tissues from 
blocking of the reticular and lymphatic spaces. The pus keeps on 
destroying tissues in proportion to the niunber of polymorpho- 
nuclear leukocytes which are present in it, and the tension under 
which it is held. In an ordinary mycotic abscess of the thigh, 
what does one do? One just removes the tension and the tissue 
destruction stops. It is not necessary to go in and clean out 
the abscess and scrape its walls. One removes the tension by 
opening the abscess, and one keeps the tension down by main- 
taining free drainage as healing takes place. 

I said the tissues were destroyed by the necrobiotic and toxic 
action of the pus under tension in proportion to the number of 



CLINICAL TALKS ON DLAGNOSIS 917 

polymorphonuclear leukocytes contained in it. Why do the 
polymorphonuclear leukocytes tend to destroy the tissues where 
they are held in loco? It is because of the trypsin which they 
contain. It is the trypsin which does the mischief through its 
ability to digest the proteins of which the body tissues are made. 
In a case of purulent meningitis the toxic and necrobiotic action 
of the pus is enhanced by the inelastic wall of the cranium, which 
cannot give and stretch like the soft tissues. The evil effects of 
pus under tension are exerted in double measure on the delicate 
and vital elements of the brain because of the absolutely un- 
yielding character of the cranium and the relatively sHght extent 
to which the brain itself can give way because of its inclosure in 
this bony box. Somewhat the same conditions obtain as with 
a central osteomyelitis. The center of a long bone is soft, but 
it has an inelastic wall about it, the cortex; consequently, de- 
struction of the medulla progresses at an alarming rate, and ex- 
tensive or complete destruction of the marrow may ensue be- 
fore the cortex shows any appreciable gross involvement. The 
same is the case in infections of the brain, the infection early 
forcing its products into the circidation, rendering the adjacent 
brain tissue first ischemic and then necrotic. Dr. Mix is punctur- 
ing the spinal canal as a part of the treatment of the case, not 
merely as a diagnostic measure; and the procedure will be re- 
peated tomorrow and the next day. He notices today a pro- 
nounced change in the character of the fluid since yesterday. It 
is much less purulent. 

What will be gained by this patient from this procedure? 
Let us see. The microorganism present in the spinal fluid is the 
pneiunococcus. Pneumonia is a self-limited disease. It pro- 
duces its intoxication early and promptly, and its microorganisms 
are destroyed, if the patient survives, at a definite date regularly 
— in children, from the seventh day on; in adults in midlife, 
about the ninth day, as a rule; in the senile, on the eleventh or 
twelfth day. In the early days of bacteriology it used to be 
thought that the non-fatal cases of these infections got well be- 
cause the invading organisms were destroyed by intoxication 
from the progressive increase of their own toxins in the circulat- 



9l8 CLINICS or JOHN B. MURPHY 

ing medium of their host, just as bacteria gradually die out, in 
the course of time, on culture-media in vitro. We know now that 
the microorganisms are destroyed in these non-fatal cases of in- 
fection by the action of antitoxins and antibodies produced by 
the host's body tissues and blood-cells, a radically different and 
far more hopeful theory than the former, for it points out to us 
a road to cure. In this case treatment is chiefly a matter of carry- 
ing the woman along a sufficient number of days with supportive 
treatment until this infection subsides, that is, is overcome by 
antibody formation. If one can prevent the progressive increase 
in intracranial and spinal pressure from developing to a fatal de- 
gree during the time the infection is active, and if other foci of 
pneumococcus infection do not arise elsewhere, she may get well; 
but we know from experience that pneumococcus meningitis 
has a very dubious outlook, because of the practical difficulties 
in meeting successfully these therapeutic indications. What we 
need most, and still hope for, for these cases is an antipneumo- 
coccus serum of real efficiency. There is none yet. 

Pneumococci are present many times in the mouths of normal 
individuals. In persons who have had pneumonia once the 
organism is present in the mouth in 60 per cent, of the cases. 
In those who have had the infection twice the organism is present 
in the mouth in almost 100 per cent, of the cases. It is present 
in the mouth' under normal conditions in an enormous number of 
cases who have never suffered from any active manifestation of 
pneumococcus infection. So numerous are these pneumococcus- 
carriers that the astonishing feature about them is that the 
pneumococci find entrance into their blood so rarely. What we 
should wonder at is that we have so little pneumonia — not so 
much. Although the organism often appears to act merely 
as a harmless saprophyte, yet when it does find entrance into the 
blood through the tonsils or alveolar processes, or through the 
pharyngeal or bronchial lymphatics, or through infection of an 
artery or vein, it often produces one of the most virulent types 
of general infection that is possible. Following the extraction 
of teeth and in connection with fractures of the jaw there not 
infrequently develops a pneumococcus infc'ction spreading from 
the site of injury. 



CLINICAL TALKS ON DIAGNOSIS 919 

I recall one case that occurred on my service at the Presby- 
terian Hospital. A boy had a tooth extracted. He had a little 
more pain that night than he had had during the day. The 
next day he had a chill. Finally, on the second day after the 
extraction, he was brought to the hospital. On the morning of 
the third day a pure pneumococcus culture was grown from his 
blood. Then he had another chill. Then he commenced to 
show signs of an acutely developing endocarditis, of which Dr. 
Mix said this patient has no manifestations, which is proof that 
the infection is still held within her cerebrospinal tract. When 
the endocarditis was in full bloom, the boy's heart valves com- 
menced to throw off emboH. These emboli were carried by the 
arterial stream to various organs in the body. First he had a 
gangrene of the right leg; then an infarct in the kidney with 
blood in the urine; then an infarct in the spleen; then in the 
lung; he developed a bloody expectoration from the multiple 
infarcts in the lung; then came a gangrene of the left arm. He 
lived on until, finally, one morning an embolus sKpped into one 
of his cerebral arteries; he was dead in thirty seconds. 

I cite this case merely to show how numerous and deadly the 
infective emboK may be and how rapidly they are sometimes 
thrown off in an intravascular infectious process, particularly 
when the infection is virulent and located on the valves of the 
heart. There are in the museum of Rush College the speci- 
mens of this case, obtained at autopsy. Every one of these 
emboli is preserved and the specimens are arranged in temporal 
order, showing the sequence in which they occurred. And all 
this beautiful pathologic collection came from the simple ex- 
traction of a tooth ! 

One of the other conditions in which there is great danger of a 
compHcating pneumococcus infection is fracture of the base 
of the skull, and particularly that type of fracture where there is 
an escape of cerebrospinal fluid. Such a case, for instance, as 
we had here some ten days ago, runs a great risk of acquiring a 
fatal pneumococcus meningitis. The patient had, if you re- 
member, a fracture of the base of the skull, with the cerebro- 
spinal fluid — a clear fluid — discharging from his nose for many 



9J0 CLDflCf Of JQHV 3. UVWnX 

(Uyf after the injury. Finaliy, however, the openiiig doied ^>, 
tad the dftoger of infection wai over; but such ii not tlwayi the 
outcome, the opening occiitoniilly renutining patent and dis- 
charging for montha and yeart . I recall a caae occurring in my 
very early practice— a child who had a discharge of cerebrospinal 
fluid follondng a fracture of the base of the skull. The disdbaige 
persisted for siic or eight years* I was conjecturing an io how 
to doie the opening by operation when, all of a sudden, ti" <)hM 
developed a pneumonia which went on to a rs|rfdiy i 
mhiation, perhaps a fortunate occurrence for the child fur it 
abeady commencing to show vicious mental symptoms with <& 
gradually progrwslve uptkpty. 

Dr. Mix will show you these cases again from time to time, 
provided they do not die. It is deliig^tfui to be able to study 
cases of this dass worked up in so sdentiflc a way, so that otic 
knows Just what one is doing at every step and why. Every 
phase <rf the disease has been worked out in these caies by Dr. 
Mix and i<> ' (ants. One also knows, unfortunately, lome 
of tin 111. of then^ in these cases. For this patient 

I I I'll ' a vaccine, and I presume that by tonight 

fthall have an auto-vacdne for her, 
' - ' nt contributing toward tiisue re- 
body resistance to the infective 
a^ent. Hy m i ' t 'I hjmbar punctures Dr. Mix witi 

try I ) 1 'p iritracranial pressure, the im- 

»»' .. which this patient shows. I 

Mix take a half-hour of my clinic 
time to »how lhe«c two • < ! Iicy »hlnc.' by mutual con- 

^ '" <dricicnily (uiiiiK ake one wish to know 

<nd to kfx^w ii i> ict way, SO that when 

M« iiiilcr observation he will not 
Itiivc t my early ckys of medical 

pri' t! 'trnily, the patients 

o\ \n i u i oHated, living on 

South Morgan Sir. ilh. t)r i ' i-s a very able 

iinl a !horou;/,li < lii.i' i.iti Ff< Ii.ul 

t.',:!.,:t:. : ilv fiit a I«'iu' till ' UllC ul I wo 



(^f^ 




922 CLINICS OF JOHN B. MURPHY 

death. On the ninth his pulse was 120 at 9 a. m.; 144 at noon; 
148 at 3 P. M. ; 160 at 6 p. m. ; and 150 at 1 1 p. m. On the morning 
of the tenth the nurse was unable to count his pulse, but re- 
corded it as 150 at 3 A. M. and 158 at 4 A. M. After that the 
pulse is recorded only with a question mark. The patient ex- 
pired at five minutes to six, May loth. The patient with the 
pneumococcic meningitis had the same kind of an ending, d}dng 
at 9.45 p. M. on the ninth of May. At noon on the ninth her 
pulse was 100; i P. M., 106; 3 p. m., 112, as she became uncon- 
scious. At 6 p. M. her pulse was 158; at 8 p. m. 163; at 9 p. m. 
it is recorded as 154.] 



PERINEPHRITIC ABSCESS, PROBABLY EMBOLIC IN 
ORIGIN.— OPENING AND DRAINAGE 



HISTORY 

The patient is a married woman aged forty years. Her 
family history is negative for tuberculosis and carcinoma. Her 
husband and four children are Uving and well. Her past history 
is negative. Menstruation began at sixteen years of age, was of 
the twenty-eight-day type, regular, never painful, and usually of 
three days' duration, the patient using three or four napkins 
a day. Her last menstruation occurred April 9, 19 14, and was 
normal. 

The patient became pregnant in December, 19 13. She con- 
tinued in good health until February 15, 19 14, when, without 
apparent cause, so she tells us, she aborted. She did not flow 
after the abortion. No instruments were used and no internal 
examination made. She was attended by a midwife. She was 
up on the third day following the miscarriage, feeling in her usual 
health, and remained perfectly well until about one month later, 
when, on the evening of March 20, she had a severe chill, which 
lasted about fifteen minutes, followed by a high fever. The next 
morning she felt considerable pain in the left loin over the region 
of the kidney. The pain was not sharp or cramp-like, but dull 



CLINICAL TALKS ON DIAGNOSIS 923 

and boring in character, and radiated all through the upper 
abdomen. On the evening of March 20 she noticed a tender 
area on feeHng of the left side of the abdomen at the site of the 
pain. This tenderness has continued. She had no more chills, 
but the fever continued high — how high she does not know. 
About one week later the tender area on her back became swollen 
and the pain increased. About April 10 she consulted a doctor, 
who advised her to come to the hospital. Ever since the onset 
of the illness she has felt pain in the left side of the abdomen and 
in the back, and has had scalding sensations on urinating. She 
has never passed blood or pus in the urine, so far as she knows. 
She has been stubbornly constipated since the miscarriage. The 
stools have always been normal in color. She has had no inter- 
menstrual flow and has never vomited. 

Examination. — There is a mass on the left side of the abdo- 
men, extending from the lower margin of the ribs to a point one 
and a half inches above the posterior superior iliac spine, and from 
a little on the left side of the vertebral column to the anterior 
axillary line. The mass is hard, pits on pressure, and is not 
movable; the tissues over it appear inflamed. Palpation causes 
severe pain. Vaginal examination is entirely negative. 

Laboratory Findings (April 16, 19 14). —Leukocytes, 
13,600 per c.mm.; hemoglobin, between 70 and 80 per cent. 
The urine (freshly voided specimen) contains no albumin, casts, 
or sugar; odor normal; specific gravity 1015; no red cells; the 
white cells average five or six to the field of a >6 dry objective. 
The stools give a weakly positive test for blood with the guaiac 
method. 

COMMENTS AND OPERATION 

Dr. Murphy (April 17, 19 14): What is the matter with this 
patient? 

Intern: I shouldn't be surprised if she has a psoas abscess. 
I think a tubercuHn test might be made to clear up the diagnosis. 

Dr. Murphy: The trouble began with a chill and an ele- 
vation of temperature. There was some soreness in the left loin 
within twenty-four hours of the onset. Is that the history of a 



924 CLINICS or JOHN B. MURPHY 

psoas abscess? Does one have to make a tuberculin test to 
differentiate the fact that the condition is not a tuberculosis? 
Not at all. The doctor lost sight entirely of the relationship 
between the urinary symptoms and the pain in the left side. 
Just a few days after the onset of the pain the patient noticed 
burning on urination, which lasted for a few days, with no pain re- 
ferred to the region of the bladder. We have had two similar cases 
within the last two weeks. Both patients came into the hospital 
with the history of urinary irritation — burning on urination. 
Then, after several days, came the severe pain in the loin. Both 
cases were infections in the pelvis of the kidney. One patient 
came in diagnosed appendicitis, expecting to have an appendec- 
tomy performed. The other patient came in with a rather in- 
definite history, but her doctor believed the condition to be a 
gall-bladder lesion. It was only the patient's story in both of 
these cases that kept me from performing an immediate opera- 
tion. One patient has already gone home, and the other is ready 
to go home either today or tomorrow, without any operation in 
either case, only medical treatment. If we had removed the 
appendix of the first patient, she would have had no relief of her 
trouble, but, very likely, an exacerbation of it. If we had drained 
the gall-bladder of the second patient she would, sooner or later, 
have had recurring chills and fever, but without jaundice, and this 
combination of symptoms would also have told us to look for a 
lesion outside the biliary tract. It is better, however, to study 
the patient's history before operation and avoid mistakes. Then 
you'll not have to cover them up later. 

This patient's story is not a perfectly clear one. She noticed 
the urinary irritation only after the pain in the kidney set in, 
not in the beginning of the trouble. Both of the other patients 
gave us the story of a vaginal discharge, then trouble with 
urination, and, finally, the pain in the loin. This history gives 
us just the same symptoms, but in reverse order, if we have re- 
ceived it correctly from the interpreter. The patient herself 
talks only Italian, and we, therefore, labor at a disadvantage, 
since we can get her statements only through the uncertain 
medium of a lay mind, not too intelligent and sans education — 
medical or scientific. 



CLINICAL TALKS ON DIAGNOSIS 925 

We cannot consider tuberculosis of the kidney in this case 
because tuberculosis of the kidney does not begin with a chill and 
does not produce obvious swelHng and pain within the first 
twenty-four hours of its onset. Tuberculosis of the kidney often 
produces signs of bladder irritation for weeks, months, and some- 
times years before local signs or symptoms develop in the loin. 
Here the patient had local manifestations of renal disease within 
the first twenty-four hours of her illness. 

This condition cannot be a hydronephrosis, because an un- 
complicated hydronephrosis does not set in with a temperature 
of 105° F. and a leukocytosis of 13,600, although there may be, 
and usually are, pain and swelling, and the urinary findings are 
not unlike those present here. 

A pyonephrosis, too, is extremely unlikely here, because a 
pyonephrosis would be accompanied by pus in the urine unless 
the ureter were completely blocked. If the ureter were ob- 
structed she would have pain and retention of urine, the pain 
being due to the tension on pelvis and ureter produced by the 
retained urine. The patient did, in fact, have a marked reten- 
tion of urine. I was called on the phone, at the office, yesterday 
afternoon, and told that this woman had not urinated for twenty- 
four hours. Why? Was the ureter blocked or kinked? Prob- 
ably not, because on catheterizing the patient we removed 300 
c.c. of somewhat cloudy urine! There was no odor to it, but 
microscopic examination showed the white cells present in the 
sediment to average slightly over 15 to the field of a ^ dry 
objective. There were no casts or red cells found. If this 
patient had a pyonephrosis with a lump in her loin as large as 
this one is, she should have not merely 15 white cells to a field, 
but, more nearly, 1500. 

Much more likely than any of the conditions which we have 
yet considered is a perinephritic abscess. The sudden onset with 
pain, tenderness, and swelling in the loin, accompanied by high 
fever preceded by a chill, leukocytosis, and, finally, the de- 
velopment of an exquisitely tender, boggy mass in the renal 
region, all speak with positiveness in favor of this diagnosis. 

Having concluded that we have here a perirenal abscess, we 



926 CLINICS OF JOHN B. MURPHY 

must next ask ourselves its etiology. To determine this point, 
as a rule, we have to rely largely on the history; but the patient's 
anamnesis, in this case, leaves us still searching in a fog for the 
ultimate cause. If we consider first the possibility of sepsis 
following the abortion to be the cause, we must presimie that the 
infection spread upward by extension retroperitoneally, per- 
haps along the periureteral lymphatics. An ascending infection 
may follow this route, whether it originates in the bladder as an 
acute cystitis and ureteritis, or in the uterus as an endometritis, 
followed by deeper lying uterine infection, which spreads readily 
to the retroperitoneal cellular tissue on the side of the uterus 
where the ureter lies beside the uterine blood-vessels. By a very 
similar retroperitoneal route a metastatic abscess may form 
around the left kidney after an acute inflammation in a retro- 
peritoneal appendix vermiformis. 

Let us analyze the patient's story again. She had an abor- 
tion, cause unknown, about the middle of February of this year. 
A month following that abortion her present illness began sud- 
denly with a chill. We are unable to elicit any history of pal- 
pitation or other cardiac disturbance with, preceding, or following 
the chill. Then she had a sudden and rather severe pain in her 
left loin, persistent, aching, and boring in character, not sharp or 
cramp-like. She had an elevation of temperature to 105° F. 
The suddenness of the onset, the month's freedom from all 
symptoms of pelvic trouble after the abortion, make me think 
that, in all probability, she had a septic infarct in the cortex of 
the left kidney, possibly originating as a thrombus. This septic 
infarct, which produced sudden, intense local pain, a single chill, 
then fever, formed an abscess which evidently did not rupture 
into the pelvis of the kidney, but into the perirenal tissues. If 
it had, on the other hand, ruptured into the renal pelvis, the 
patient would have had large quantities of pus and, probably, 
blood escaping into the urine. One of the features of the urine 
when the renal cortex is involved in a septic process, or even when 
there is only a perirenal abscess, is an increased number of leu- 
kocytes in the urine, and occasionally a blood-cell. Large 
quantities of pus in the urine in these cases are sometimes found, 



CLINICAL TALKS ON DIAGNOSIS 927 

but need not be present, depending on the degree of cortical in- 
volvement. If an abscess is in the renal cortex, the most com- 
mon place for it to rupture, following the Hne of least resistance, 
is outside the kidney. That this patient has now a perirenal 
abscess is certain. That it is of embolic origin is very likely, in 
spite of the entire absence of cardiac manifestations. It is not 
necessarily true that the embolus came from the abortion, either 
directly or indirectly. It could have originated from an infec- 
tion in any other portion of the body, and yet lodge in exactly 
the same place that it did. Where the primary focus was, we 
are unable to say. The patient also gives no history of a pre- 
ceding bladder infection to account for the extension upward of 
a ureteral or periureteral infection. She has no distinct history 
of an infection in the pelvis to account for the upward extension 
nor the local findings which accompany a pelvic infection. She 
has merely the history of sudden loin pain, accompanied by acute 
septic manifestations, a syndrome characteristic of a septic em- 
boh'sm in a rich lymphatic zone, such as we have in and around 
the kidney. 

Some of you doctors look surprised that I speak of the kidney 
region as one rich in lymphatics. In the days that many of you 
and I studied anatomy we were taught that the renal region was 
poor in lymphatics. In recent years, however, Stahr, who has 
made a prolonged study of the subject, has shown that the kidney 
itself possesses a very rich network of lymph capillaries, while a 
second network lies in the deeper layers of the fibrous capsule, 
and a third and very extensive network lies superficially in the 
fatty capsule. These two perirenal networks communicate 
freely with each other, and also with the lymph-vessels of the 
cortex of the kidney. 

Judging by the clinical aspect of the case, the abscess does not 
communicate with the renal pelvis. If such proves to be the 
case, we shall simply open and drain the abscess from behind. 
If the renal necrosis extends high enough to involve the hilum 
of the kidney, urine will have escaped into the abscess cavity, 
and urine, as well as pus, will drain subsequently from the wound. 
It is our opinion, however, that the abscess does not involve the 



928 CLINICS OF JOHN B. MURPHY 

pelvis of the kidney, but only the cortex. Why? Largely be- 
cause the patient has had only 15 pus-corpuscles to the micro- 
scope field, and no red cells. The presence of a slight amount of 
blood in the stool suggests that the abscess lies close to the bowel, 
and might perforate into the latter if surgical intervention were 
long delayed. 

The time element in the development of disease is one of the 
important factors to be taken into consideration in all diagnostic 
work. The patient's own story is probably the most important 
single factor in diagnosis, and in the patient's story the time 
element is one of the extremely vital points, particularly the 
time relation of the individual symptoms and their order of oc- 
currence. At the recent meeting of the American Surgical 
Association in New York, and for the first time in all my connec- 
tion with medical societies, the keynote in the diagnosis of 
practically all the conditions under discussion at the meeting 
proved to be the clinical history. In this clinic we have been 
insisting for a quarter of a century that the patient's own story 
is of paramount importance. In duodenal ulcer, gastric ulcer, 
in hepatic lesions, in gall-bladder lesions, the members of the 
Surgical Association brought out the fact that the clinical history 
in diagnostic importance takes precedence over all other evidences 
of disease. The history of this patient of today is extremely 
important, even though not perfectly typical, apparently, of the 
condition present. 

[Dr. Murphy made the usual oblique lumbar incision through 
skin and fascia. In cutting through the latissimus and serratus 
magnus muscles down to the lumbocostal fascia it was noted that 
the soft tissues were already infiltrated by the inflammatory 
edema. Pus welled out of the wound immediately, showing 
that the lumbocostal fascia was incised. — Ed.] 

Dr. Murphy: We shall make a vaccine from this pus. 
There is no odor to it, which means that the organisms causing 
it are probably not anaerobes. The pocket extends clear down 
to the kidney, meaning that the suppuration was primary in the 
kidney and has ruptured posteriorly, producing this burrowing 
abscess. The abscess, therefore, was probably embolic in origin. 



CLINICAL TALKS ON DIAGNOSIS 929 

That there is no odor to the discharge would speak in favor of 
cortical renal origin, whereas if the condition had originated 
from the renal pelvis or from the intestine, stomach, or bone, 
there would probably be a mixed infection present and an odor. 
The rib is not involved, although bathed in the pus. 

To summarize: All the soft tissues in the loin were found 
infiltrated; the pus burrowed under and around the twelfth rib, 
but the costal periosteum is still intact; the pus extends down 
to the surface of the kidney, thus verifying the cHnical diagnosis 
of perirenal abscess. We are inclined to believe, from the clinical 
history, that this suppuration originated from a septic infarct 
from some unknown source. A large rubber tube was inserted 
as a drain. As we stated before beginning the operation, the 
abscess does not communicate with the pelvis of the kidney, for 
if such had been the case, the urine examination would have 
shown a great many more pus-corpuscles than 15 to the field of 
a ^ dry objective. 

[Note. — ^The wound drained freely and the temperature re- 
turned promptly to normal. The patient left the hospital at the 
end of two weeks, and dressings were continued by her home 
physician. She has not returned to the clinic for reexamination 
up to August I, 1914. — ^Ed.] 



VOL. Ill — 59 



TRAUMATIC EPILEPSY. — ADHESIONS BE- 
TWEEN SCALP AND DURA THROUGH AN 
OLD TREPHINE OPENING. — ADHESIONS 
BETWEEN DURA AND CEREBRAL CORTEX. 
—OSTEOPLASTIC FLAP OPERATION AND 
FREEING OF ADHESIONS. — SUBSEQUENT 
COMA AND DEATH 



HISTORY 
' The patient, a man twenty-four years of age, entered the 
hospital June 15, 19 14, with the following history: When four 
and a half years old (in 1894) the patient was kicked by a horse 
on the left side of the head just above the parietal eminence. 
The skull was fractured. A surgeon removed from the skull a 
broken piece of bone about one and a half by three-quarters of 
an inch wide. The patient made a rapid recovery from the op- 
eration and remained apparently well until three years ago (191 1). 
One night in May of that year he called his father, who came from 
an adjoining room and saw the son, within the course of two or 
three minutes, seized with a twitching of the muscles of his face, 
legs, and arms. The eyes rolled upward. The patient remained 
unconscious during the attack and for one to two minutes after 
it had passed. 

Since this initial attack the convulsions have recurred re- 
peatedly. His arms and legs sometimes become rigid following 
the attacks, usually on the right side; he is usually hazy mentally 
for about twenty minutes after the convulsion, and then drops 
off to sleep for from fifteen minutes to half an hour, awakening, as 
a rule, with a headache which lasts for from four to eight hours. 
He feels very tired after an attack. 

The first attack occurred May 20, 191 1; the next one on 
July 4, 191 1. The attacks continued, from one to two weeks 

931 



932 CLINICS OF JOHN B. MURPHY 

apart, all that summer and until October, 191 1. On October 
28, 191 1, a cranial operation was performed The cicatricial tissue 
at the site of the former skull fracture was removed and the 
skin-flap sutured back into place, so the father relates. For 
six months following this operation benefit was apparent; but 
after that time the attacks gradually became less frequent, rang- 
ing from three to six weeks apart. From February, 1913, to 
November i, 19 13, the patient enjoyed complete freedom from 
convulsions, no particular reason for that freedom being assigned; 
but since that time the attacks have averaged about one every 
week or two. From the middle of February to the beginning of 
April, 19 14, the attacks again ceased. Since April they have 
averaged about two each week. The last convulsion occurred 
on June 7, 19 14. 

In June, 1909, the patient was struck in the left temporal 
region by a baseball. He felt weak for the remainder of the 
day. He has not been able to stand the direct heat of the sum- 
mer sun ever since this second accident occurred, because of the 
headache which the sun's rays seem to cause him. 

COMMENTS AND OPERATION 

Dr. Murphy (June 17, 1914): What was the date of the 
original accident? 

Intern: 1894. 

Dr. Murphy: Twenty years ago, and his epilepsy did not 
manifest itself until three years ago! Seventeen years is an 
extraordinarily long incubation period for a traumatic epilepsy, 
isn't it, doctor? 

Intern: I do not know. 

Dr. Murphy: The most valuable portion of my medical 
experience has been derived, I believe, from the fact that during 
all these years of my practice, and in spite of the not inconsider- 
able labor which it involves, I have not only seen, but also ex- 
amined carefully, practically every patient on whom I have ex- 
pected to operate. That is my system. Its significance is 
beautifully illustrated in this case. This intern is probably as 
good as the average intern. I might concede that he is a little 



TRAUMATIC EPILEPSY 933 

better than the average if I were not afraid of inflating him with 
praise. And yet he left out of that history one of the most vital 
facts in the whole case. He omitted entirely to tell us of the 
fact that this boy, after being struck with a baseball five years 
ago, remained unconscious for from twenty to forty minutes 
after the accident. What is one to say of such an omission? 

The patient was struck not at the place where the bone had 
been removed at the operation fifteen years before, but a little 
lower and farther in front. That lapse of consciousness, al- 
though of only short duration, was a serious sign. Not the fact 
that the patient was struck with a baseball, but the fact that 
that blow was severe enough to render him imconscious, means 
that this second injury was fraught with dangerous possibilities. 
I have often said that I had rather die than receive a blow suffi- 
ciently severe to render me unconscious for a considerable period 
of time. The late sequences of this type of injury I have ob- 
served for many years, and I wish none of them mine. A blow 
which merely fractures the skull without producing unconscious- 
ness, such as that from a sharp instrument, is not nearly so 
serious a condition from the point of view of future possibilities 
as that following the blow of a blunt instrument which renders 
the patient unconscious. 

When this patient was kicked in the head by the horse twenty 
years ago, notwithstanding the fracture of the skull which neces- 
sitated decompression, he was not rendered unconscious; but 
when he was struck by the baseball five years ago he remained 
unconscious half an hour or more. He was not first stunned, 
then conscious, subsequently lapsing again into unconsciousness 
— the sequence which is so typical of bleeding from the middle 
meningeal artery. He was rendered unconscious immediately, 
and when he came out of coma he remained conscious continu- 
ally thereafter. 

This is a typical case of traumatic epilepsy, originally of the 
Jacksonian type, but now closely bordering on the grand mal 
type. Let me recall to your minds the different varieties of epi- 
leptic attacks. The Jacksonian attack begins in one extremity 
or, less frequently, in two, with twitching, which slowly spreads 



934 CLINICS OF JOHN B. MURPHY 

until it may involve the whole body, and be accompanied by 
complete unconsciousness; or it may be confined to the original 
regional twitching, without loss of consciousness occurring. 

In the petit mat type of epilepsy the patient, perhaps while 
sitting or talking or being otherwise actively occupied, suddenly 
but only momentarily loses consciousness. The expression of 
the face may not change for a minute. After a minute, a half a 
minute, or even a few seconds, the patient starts doing whatever 
he was previously engaged in, just as though nothing had hap- 
pened, because he himself is unaware of the momentary hiatus; 
and even his iramediate family may be a long time in compre- 
hending the significance of these lapses. There may be one or 
twenty or fifty of these "psychic equivalents" in a day. The 
patient may be singing and, after a moment's pause, starts 
again on the same note. He may be playing the piano and, after 
the interval, strikes the next key correctly. That is the petit 
mal type of epilepsy, a momentary flash of complete coma, un- 
accompanied by convulsions. The petit mal attacks usually pass 
over sooner or later into the convulsive form of epilepsy. Unlike 
the Jacksonian, they have no aura, or premonition as to what 
is about to happen, and know nothing of their subsequent mental 
lapse; but they may have a Httle psychic haziness or incoherence 
following the attack. The nature of these attacks is often by 
no means obvious, either to patient or practitioner, and so they 
have gained the name of "masked epilepsy." 

The grand mal attack consists of severe convulsions, which 
come on usually without a moment's warning, or may be pre- 
ceded by an aura of some sort, psychic or somatic. The epi- 
gastric aura is rather the more common. The patients fall to 
the ground, wherever they are; there is first a short period of 
generalized tonic muscle spasm followed by twitchings, which are 
at once, or soon become, general over the whole body, continue 
for a certain time, and are accompanied and followed by com- 
plete loss of consciousness for a longer or shorter period. After 
this profound sleep they finally wake up with a headache and 
some mental confusion or torpor. 

We arc unable to tell with certainty from this patient's his- 




•m' 



Fig. 270. — Traumatic epilepsy. Adhesions between scalp and dura through 
an old trephine opening. Adhesions between dura and cerebral cortex. This 
postero-anterior radiogram shows the cranial defect in the left parietal region, 
where a piece of bone was removed in 1894 from the patient's skull following a 
compound fracture of the skull the result of a horse-kick. The adhesions between 
the dura and the scalp, on the one side, and between the dura and the cerebral 
cortex, on the other, were situated beneath this opening. In operating. Dr. 
Murphy's osteoplastic flap included a large area of bone containing this cranial de- 
fect in its center. 



935 




Fig. 271. — Traumatic epilepsy. Lateral view of the skull (right side of face 
on the plate), showing the cranial defect in the left parietal region. The pointed 
light area seen just below the vertex of th6 skull is an erosion made by a large 
Pacchionian granulation, a not infrequent normal finding. 



936 




Fig. 272.— Traumatic epilepsy. Lateral view of the skull (left side of face on the 
plate), showing the cranial defect in the left parietal region. 



937 



TRAUMATIC EPILEPSY 939 

tory whether it was the baseball or the horse's kick which is re- 
sponsible for his present condition; but of the two I should con- 
sider the baseball injury the more serious. [OutHnes the scalp 
incision by passing Makka's long flexible hemostatic clamps just 
outside the proposed line of the flap.] We shall make our in- 
cision well within these lines of clamps. The bleeding from the 
scalp is much lessened by passing this long Makka's clamp along 
the skull in the temporal region, and clamping the overlying 
scalp with it. The construction of the instrument is simply that 
of a long flexible spring clamp. [Makes incision down to the 
skidl.] Most of the bleeding is coming from the inner side of 
the scalp incision, because the patient has on the other side a scar 
which is relatively avascular. I do not like to operate these 
cranial cases that have been operated previously. They usually 
have dural adhesions; and the dura is often so fixed that one 
cannot get around it well, and is often torn by whatever cutting 
instrument one uses to open the skull. [Makes the first opening 
in the skull with the Neff trephine.] I dislodge the dura from 
the inner surface of the inner table with the dural separator 
(Braatz sound). Then I start with the shoe of Nefl's drill out- 
side of the dura" and close to the skull, and endeavor to keep the 
shoe of the instrument outside of the dura all the time while I 
am cutting the bone-flap with the drill. When the drill works 
at all, it works rapidly and effectively. Perhaps it tends to pro- 
duce a little more diploetic hemorrhage than the De Vilbiss for- 
ceps. The old scar runs clear to the midline of the scalp, to a 
point over the longitudinal sinus. 

[Cuts out a large bone-flap with base downward.] 
With the Doyen chisel I must blaze the way in which I wish 
the bone-flap to break at its base. I wish to keep and return 
the osteoplastic flap, and, therefore, hold it fast to the galea 
with the Krause claw forceps. I am likely to tear the dura in 
elevating this bone-flap, but that does not matter greatly, as I 
expect to remove a large portion of the dura anyhow. 

[Dr. Murphy, in elevating the bone-flap, separated the dura 
from the under surface of the inner table. In about the center 
of this bone-flap was the trephine opening made in 191 1 by the 



940 CLINICS OF JOHN B. MURPHY 

patient's home surgeon. The bone had failed to regenerate over 
this defect after the operation, and the dura eventually became 
adherent to the scalp through the opening. It was, therefore, 
necessary to separate the organic adhesions between the scalp 
and the dura in order to raise the bone-flap completely. 

There was some venous oozing from the diploe when the 
bone-flap was broken off at its base and completely raised; but 
this hemorrhage was promptly stopped by the use of Horsley's 
bone wax. There was no cerebral pulsation apparent beneath 
the dura. The dura was spHt and the brain exposed. Fairly 
firm organic adhesions were seen between the cerebral cortex 
and dura. The dura was excised over the extent of these ad- 
hesions and egg-membrane was used to cover the raw surface 
thus produced. None of the cortex of the brain was removed. 
After the dura was opened the brain showed some pulsation and 
bulged under considerable tension, apparently, into the wound. 
The osteoplastic flap was replaced without suture or other fixa- 
tion except that the wound in the scalp was securely united with 
silkworm-gut and horsehair sutures. No drainage. A copious 
dressing of sterile gauze was apphed to the wound.] 

What are this patient's chances of permanent recovery? 
About 5 per cent. I should say. Approximately one case in 
twenty gets well and stays well. I saw just the other day a man 
on whom I operated some fifteen or eighteen years ago for trau- 
matic epilepsy. The history of his trouble is as follows: He was 
riding in a sleigh up in northern Wisconsin when the horse ran 
away and threw him out of the sleigh against a telegraph pole. 
He sustained a fracture of his skull, not compound, and was un- 
conscious for three weeks. After regaining consciousness he 
went along without further symptoms for about three years, — I 
do not remember the exact details of the case now, — ^but in any 
event he went along for a considerable period of time, apparently 
entirely free from any consequences of his injury, before he had 
his first convulsion. After the first convulsion he had many 
others in rapid sequence. He came to Chicago and we operated 
on him. That was in the days before we excised the dura in 
such cases. We made a large osteoplastic flap in exposing his 



TRAUMATIC EPILEPSY 94I 

brain, opened the dura, and found no pathology of apparent 
significance. What we did for him was practically nothing but 
a temporary decompression. The wound healed by complete 
primary union. He went home and for three or four weeks had 
no convulsions. Then he had an almost continuous succession 
of them. Dr. Lemke, who was taking charge of my practice 
while I was out of the city, went up to the patient's home and 
through our decompression opening tapped the lateral ventricle 
with a grooved director, thus letting off the intraventricular 
tension. The patient's convulsions immediately ceased and he 
regained consciousness. It was some httle time before he had 
another convulsion, and then he came back to the hospital and 
we operated on him again. We took out at that time a large 
portion of the dura covering his motor area on one side, a piece 
possibly once and a half as large as the piece I removed today. 
That happened a Httle over fifteen years ago. I remember that 
it was in 1898, just before Dr. Lemke went to the Spanish war. 
Since the second operation — the removal of dura — the patient 
has remained entirely free from convulsions or other symptoms 
of epilepsy. He went into the real estate business and developed 
into quite an important man in this city. Within the last few 
weeks the patient has had two or three slight convulsive attacks 
— the first m over fifteen years. We sent him to the country 
the other day, just for a rest. He has been doing very heavy 
work and bearing much responsibility in connection with his 
business, and we thought possibly that complete rest might re- 
store to him his usual immunity to these epileptic manifestations. 
The period of time which may elapse between the trauma and 
the first convulsion is very great. One patient I had was a 
young man who suffered a comminuted fracture of the skull when 
he was a baby. He fell from a second-story window on to the 
stone pavement. It was twenty-two years after that injury 
that the patient had his first convulsion. He was then holding a 
clerical position in a bank, where he was mentally greatly taxed 
and had much responsibility. He had developed rapidly, and, 
in fact, almost precociously, in school in the interim, as many of 
the epileptics do. He always did work above his grade in school. 



942 CLINICS OF JOHN B. MURPHY 

In operating on him we took a large area of the dura; but he de- 
rived little or no benefit from the operation. Why? Probably 
because his injury was a comminuted fracture which involved the 
base of the skull as well as the vertex. He had no depression 
whatever on the surface of the skull. There was only the scalp 
scar left to show he had had an injury there. That has been the 
usual outcome, according to my experience, in the cases of 
traumatic epilepsy resulting from severe injuries to the skull. 
Therefore, when the patient has suffered an extensive cranial 
injury, as from a fall, or when the skull fracture has involved the 
base, I do not operate for the epilepsy, because operation rarely 
or never benefits them. 

It is the irritation of the dura, I believe, which plays the most 
important role in the production of traumatic epilepsy. It is 
the removal of the dura over that zone of injury which gives 
the patients the greatest benefit. The time was when we ex- 
cised not only the dura, but also the outer layer of the motor 
cortex, when the latter lay just underneath the pressure area. 
This more extensive operation did not give so good results as 
the simple removal of the dura. For a time we used a silver 
plate to plug the trephine opening. Now we use the osteoplastic 
flap practically all the time, turning it back into place as we did 
today, as soon as we are through with our intracranial work. 
The circulation through the diploe of the bone-flap was very 
good in this case, notwithstanding that there was a defect in 
the center of our flap where the bone had been removed at the 
previous operation and had failed to regenerate. We freshened 
the edges of this old opening and, I believe, it may fill in with 
bone and heal over nicely. That area of dura which we removed 
was irritated by its fixation to the scalp through the old trephine 
opening in the skull. The egg-membrane which we planted over 
this area will prevent the development of scar tissue between the 
scalp and the cerebral cortex, and thus allow new bone to bridge 
the old operative gap. We hope that the presence of bone will 
have a less irritating influence on his motor cortex than did the 
scar tissue from the scalp. Brown-S6quard believed that it was 
the irritation of the dura which caused epilepsy in these traumatic 



TRAUMATIC EPILEPSY 943 

cases, and he made some experimental demonstrations at Rush 
Medical College when I was a student, showing that irritation of 
the dura, in pigeons at least, could produce convulsions. He was 
then traveling around the world making these demonstrations, 
and striving to gain a general acceptance of his views. His 
work impressed me at that time. As I became older and had 
greater experience with these cases I came to believe that his 
estimate of the situation was fairly correct. The reason that 
the basal fractures give such poor post-operative results is be- 
cause the surgeon cannot control the dura over the base of the 
brain, because it is inaccessible with our present operative technic. 

Let the record show that there were organic adhesions be- 
tween the dura and the scalp, which we freed, without opening 
the dura, in the process of turning back the osteoplastic flap; 
that there were also organic adhesions between the dura and the 
pia and cerebral cortex; that there was considerable bleeding 
on freeing these last adhesions; that this hemorrhage was con- 
trolled by catgut sutures on fine needles; that we removed an 
area of the dura measuring about one and three-quarters by two 
inches; that we covered all the denuded area of cortex with egg- 
membrane, overlapping the dura with it over its entire circum- 
ference; that the osteoplastic flap was then replaced in the reg- 
ular way; that the boy was ordered put to bed at once with the 
head of the bed elevated a distance of eight inches; that his head 
is to be kept elevated in transit to his room from the operating- 
amphitheater. 

[Note. — ^Thirty-six hours after the operation the patient 
developed a series of convulsions, went into coma, with a marked 
rise of temperature. The wound was immediately opened, but 
nothing pathologic found — no deep hemorrhage nor any sign 
of infection. The patient died eighteen hours later, never re- 
gaining consciousness, his temperature remaining high. No 
autopsy was allowed. — Ed.] 



EPITHELIOMA OF GLANS PENIS.— AMPU- 
TATION 



HISTORY 

The patient is a married man, aged fifty-five years. His 
family history is negative for tuberculosis and carcinoma. His 
past history is negative, except for the measles, which the patient 
had one year ago. Venereal infection is denied and his habits are 
good. His wife is Kving and well. 

About three months ago, in January, 19 14, he noticed a con- 
tinual irritation of the penis, which continued for about a week. 
On examining it he found under the foreskin several small warts — 
one about half the size of a pea, while the others were just visible. 
He cannot say whether the growths were attached to the fore- 
skin or the glans penis. He noticed that the largest of the warts 
had disappeared in March, 19 14, and at its site there was a small 
ulcer. During the same month he noticed that the other warts 
were beginning to ulcerate, and that if the urine touched them 
they burned. During the first week in April the foreskin became 
tight and swollen. He consulted a doctor, who said a circum- 
cision was necessary. On Tuesday, April 14, 19 14, the doctor 
split the foreskin on the dorsal aspect of the penis and discovered 
under the foreskin that the whole of the glans penis was eroded 
by deep ulcers which bled easily. He amputated the foreskin. 
A section of this pathologic tissue under the microscope showed 
it to be an epithelioma. The patient says that he has had no 
pain whatever and only a Httle discomfort from the tightness of 
the foreskin, while he has had itching and burning whenever 
urine touched the affected part, but there has been no bleeding. 
He has had no difficulty in passing urine, and has lost no weight. 
His appetite is good and his general health apparently good. 
Examination on admission to the hospital shows the glans 

VOL. Ill — 60 945 



946 CLINICS OF JOHN B. MURPHY 

penis and foreskin eroded. The involvement appears to be 
secondary on the foreskin. The inguinal glands on both sides 
are palpable. Microscopic examination of an excised piece of 
the tumor shows the pathologic condition to be an epithelioma. 

COMMENTS AND OPERATION 
Dr. Murphy (April i8, 1914): From the slide that is being 
passed one can see that the growth is an epithelioma. It is sad 
that the man allowed his condition to go neglected so long before 
calling a doctor's attention to it. When the foreskin was turned 
back, practically all the glans penis was found to be destroyed, 
and the under surface of the foreskin was also eroded. The 
epithelioma began, we believe, on the glans. The growth was 
excised, and the surgeon brought us a very good slide showing 
it to be an epithelioma. The patient must now have a high 
amputation of the penis; then he must have all the glands in the 
inguinal regions on both sides removed — an operative procedure 
which is very extensive, but necessary to prolong his Hfe. If this 
were an adenocarcinoma instead of an epithelioma, we would say 
that the hope of saving his life would be practically nil at this 
stage of the disease. Because of the involvement of the inguinal 
glands it is possible that the malignant epithelial cells have al- 
ready passed through the glands and entered the circulation and 
may now be growing in some other part of the body. A car- 
cinoma arises on the foreskin usually from the mucosa, which 
has a relatively sparse blood-supply. Therefore, it rarely ever 
has a vascular transmission. When the growth begins on the 
glans, however, because of the very rich vascularization here, it 
not infrequently leads to vascular transmission to other parts of 
the body, one of the dangers of malignant disease beginning as 
an ulcer on the glans or as an ulcer in the urethra. The same 
general rule holds true with the chancre beginning in the urethra 
or well forward on the glans penis. Practically always when the 
chancre begins in the urethra the spirochetes go directly into the 
blood, so that local measures are of no avail to abort the disease. 
Why I say that is because, although we have known about the 
^irochetes only a little time, we have known about the clinical 



EPITHELIOMA OF GLANS PENIS. — AMPUTATION 947 

course of chancre of the urethra for a long time — in fact, about 
as long as we have known much about venereal disease. A 
patient who has a urethral discharge which runs four, five, six, 
or seven months, and has also a nodule in the urethra, as a rule 
does not have the secondary local manifestations of chancre — 
the adenopathies. The spirochete goes directly into the blood, 
produces mild general symptoms which are easily overlooked by 
the patient, and it is only years later, when the infection appears 
as a spinal cord — or a cerebral — lesion that one asks the question, 
"Did you ever have syphilis?" The patient will honestly and 
firmly reply, ^'No. " But if you go into his history you will find 
that he had a "gonorrhea" of long duration, and he may be able 
to teU of the nodule. Then you make a luetin or a Wassermann 
test, and get a positive reaction. That makes you feel pretty 
certain that that patient had his chancre in the urethra, the more 
so if he gives no history of a mouth or throat trouble resembling 
a chancre. 

You can see here the place on the penis where the tissue was 
removed for microscopic examination. We must perform an 
amputation of the penis high up, and then excise all the infected 
glands. The danger here is of getting a cellular infection in the 
site of the inguinal dissection from the recent wound on the penis; 
and if we do, it is likely to give much trouble. We are not put- 
ting iodin on the scrotum, because it not infrequently produces 
blisters there which are very painful. 

We shall put the patient in the Trendelenburg position be- 
cause it gives a much better view to the visitors in the seats. 
[Incision.] There is the dorsal chain of lymphatics through 
which systemic infection most often occurs. The next step is to 
free the urethra for a considerable distance laterally, as we wish 
to preserve the corpora cavernosa. I am dissecting away with 
the urethra the corpus spongiosum, keeping close to the wall of 
the corpus cavernosum as I free it. Now we have the urethra, 
standing out with the corpus spongiosum entirely free from the 
corpora cavernosa. Now we are dividing the corpora cavernosa. 
We close up the cut end of the corpora cavernosa accurately and 
then fix the urethra to the stump. Sutures fasten the wall of 



943 CLINICS OF JOHN B. MURPHY 

the stump of the urethra and corpus spongiosum to the stiunp of 
the corpora cavernosa, so that the urethra cannot retract into 
the stump. Now I split the end of the urethra, which I have 
purposely left long, and attach it to the skin, so that there can 
be no retraction of it, and so that the stump of the penis will be 
covered entirely, either by urethral mucosa or by skin. 

Carcinomata of the penis have a great mortality, one reason 
for which is that they are usually treated on the expectant plan. 
That means expecting them to *'get ripe" before picking them 
ofif, in place of treating them early on the radical excision plan, 
which should be the method for all these malignant neoplasms 
of the penis, just as it is for those of the breast, uterus. Up, 
tongue, and other organs. If we could only perform these 
operations in time, the patients would have a very much lower 
cancer mortality. It does not seem to me that we are making 
very much progress — that we are always waiting and procras- 
tinating. It is the custom with a growth of this kind, when it 
is as large as a pea, to wait until it becomes as large as a nickel, 
" to see what it will become " ; but it is the same malignant disease 
all the time, whether it be small or large. We have often had 
occasion to refer to a lesion of the breast which resembles this 
lesion very much, from the fact that it does not destroy tissue rap- 
idly, but ultimately destroys the patient, and that is Paget's dis- 
ease of the breast, which should be called Paget's cancer. Paget's 
disease first shows as a little crust on the nipple and then as a 
larger crust. Then the lesion ulcerates and attracts notice, all 
the time increasing in size and spreading. It finally goes to the 
surgeon for excision, but usually too late to save the Hfe of the 
patient. The growth was a carcinoma when it was of wheat- 
grain size, just as much as it is when it is of dollar size. The 
important difference is that the larger lesions have been given 
time to produce metastases. The patient and the doctor may 
be idle, but the cancer is always working. 

Let the record show that the glans was entirely destroyed, 
the destruction having extended down into the corpus caver- 
Dosum. 



EPITHELIOMA OF GLANS PENIS. — AMPUTATION 949 

I am now fastening the corpus cavemosum to the skin, so 
that the skin will not be drawn too far in by the retraction of the 
urethra. Now I am covering over the remaining raw surface by 
swinging over a skin-fiap. We hope to get coaptation and 
primary healing of the wound clear up to the abdomen. I am 
excising the corpus cavernosum a httle farther so as to make an 
indentation of the skin ample to support the urethra. 

We shall not remove the inguinal glands at this time, because 
dissecting out the glands in a patient with this large quantity of 
adipose tissue would mean an enormous opening up of cellular 
spaces, which would stand in great danger of infection, in view 
of our recent handling of this ulcerated growth which we have 
just excised. If we get a primary union of this wound, it will be 
only a few days until we can take out the glands, being able to 
take them out then with practical safety against infection. We 
are fixing the urethra fairly firmly to the surface of the skin, it 
being desirable for the comfort of the patient subsequently that 
it should come well up to the surface, thus preventing the de- 
velopment of the dermatitis, which is so prone to occur on a skin 
surface frequently wet with urine. 

The mixed infection which has been present on the ulcerated 
surface of this tumor is very likely a material factor in the en- 
largement of these glands. There may be cancer metastases 
present in the glands in addition to the inflammatory swelling, 
and then, again, there may not. I am incHned to the latter, and 
hopeful, view. Now that we have anchored the urethra and com- 
plete the closure of the wound, we should insert a permanent 
catheter in most cases. But this patient is fifty-five years of age 
and has already had some irritability of the prostate. If we 
irritate it more with a catheter, we might have some serious 
trouble from it. We shall, therefore, not use a permanent 
catheter in this case but shall treat this wound just as we would 
treat a lacerated perineal wound. After each urination the field 
will be washed off with lysol, carefully dried, and then covered 
over again with bismuth subiodid powder. 

[Note. — The wound healed by primary union except for a 



. 



95© CLINICS OF JOHN B. MURPHY 

small focus of urinary infiltration close to the urethra. He had 
no difficulty in urination, and a catheter was not used. The 
patient left the hospital May lo, 19 14, with the wound completely 
healed. He is to return later for the removal of the inguinal 
glands on both sides. — Ed.] 



f 



CARCINOMA OF THE CORONA PENIS WITH 
METASTASIS IN THE INGUINAL GLANDS 



HISTORY 

The patient is a married man, aged forty-nine years. His 
family history is negative as to carcinoma. He had a chancre 
at nineteen and gonorrhea at twenty-five years of age. His wife 
has had no miscarriages and has borne him two healthy children. 

Two years ago, in January, 191 2, the patient noticed on the 
penis a small red area at the side of the corona. This spot grew 
during the ensuing year to the size of a five-cent piece. Then it 
partially healed for a time. The lesion has become slightly 
smaller now than it was. It has slightly elevated borders, is 
triangular in shape, one-half inch long, and one-fourth inch wide. 
It is constantly itching, but never painful. There are small hard 
elevations like vesicles over its surface, particularly at its border. 
Often a clear fluid exudes from the lesion, but it never bleeds. 

In December, 1 913, while bathing, the patient noticed in the 
upper right inguinal fold a small tumor, about the size of a marble, 
which was soft and red. This tumor has grown gradually until 
now it has become the size of a goose-egg and is hard in places. 
In the last week of February, 1914, he noticed in the lower 
inguinal fold another small, red, soft mass, not painful. Now 
the latter has become hard and tender and is the size of a walnut. 
He says he has had no chills or fever during this time. He 
denies recent venereal exposure. The inguinal swellings have 
never disappeared even temporarily, nor have they ever dimin- 
ished at all in size since they were first noticed. 

COMMENTS AND OPERATION 
Dr. Murphy (April 8, 1914): Did the lesion begin at the 
site of the former chancre? The history should record this 
point. When was the lesion on the penis first noticed? 

951 



952 CLINICS OF JOHN B. MURPHY 

Intern: In January, 191 2. I do not know where the former 
chancre was. 

Dr. Murphy: You say the lesion on the penis became smaller? 

Intern: Yes, sir. 

Dr. Murphy: No, doctor, you did not get that right. The 
lesion did not become smaller. I wish to emphasize that point. 

Intern: He said it did. 

Dr. Murphy: You did not get it right. You should have 
found out what made it smaller. What was done to it? Why 
do I ask that question? Because if this lesion became markedly 
smaller spontaneously, that is positive evidence that this growth 
is not malignant. If it healed over spontaneously, you could say 
positively that it was not a malignant lesion; but if it healed 
over after the actual cautery was applied, the diagnostic signi- 
ficance is entirely different. You make the differential diagnosis 
between lupus and carcinoma ordinarily by what? By the fact 
that in lupus there are some areas of healing while other areas 
are breaking down. In epithelioma, with the exception, very 
rarely, of the rodent ulcer or basal-cell epithelioma of the aged, 
you never find areas of healing. The cancer may scale over, but 
it does not heal. The course is somewhat different, however, 
when you put glacial acetic acid on such a tumor. Following 
the destruction of the tumor tissue by the caustic, you may have 
repair occurring in the normal way. How many times was the 
sore cauterized? 

Patient's Physician: Twice. 

Dr. Murphy: There is the primary lesion on the penis. The 
moment you look at it its appearance makes you suspicious of 
malignancy. He has had it for two years, and in the beginning 
it was larger than now. It was cauterized twice with the actual 
cautery. When was the last cauterization? 

Patient's Physician: About five months ago. 

Dr. Murphy: I shall take out all of that neoplasm. What 
date was it that he noticed the lump in the right inguinal region? 

Intern: December, 19 13. 

[Excision of the small tumor on the penis, together with a 
small encircling area of normal tissue of the glans and corona.] 



CARCINOMA OF THE CORONA PENIS 953 

Dr. Murphy: I shall send this specimen to the pathologist 
for examination at once. Our diagnosis of this lesion on the 
penis is that it is malignant and that it is an epithehoma. What 
is this lesion in his right groin, doctor? 
Intern: A metastatic carcinoma. 

Dr. Murphy: If so, then it is necessarily a solid tumor, is it 
not? But this is not a soKd tumor. It has fluid in it. In fact, 
there is a good deal of fluid. I thought I should get you on that 
point. I have been in there with a hypodermic needle and I was 
able to withdraw fluid. What is the matter with that groin now? 
If that is a metastatic epithelioma, it should make a solid tumor 
in his groin, should it not? But it is cystic. What is the matter 
with him? 

Intern: An infection. 

Dr. Murphy: I thought I could lead you astray there. The 
fact is that it is not necessary that the growth should be solid 
in metastatic epithehoma. Where the tumor originates from 
squamous epithelium, the secondary neoplasm may be cystic, 
as in epithelioma on the dorsum of the foot, whence you often have 
the carcinoma metastases cystic in the groin. These secondary 
neoplasms may break down in the center by liquefactive necrosis 
and thus become cystic. The fluid in these foci of softening is 
milky in appearance, but has not so many fat-globules in it as 
you find in milk. It is my conviction that this neoplasm in the 
groin is a secondary carcinoma of the inguinal lymph-glands 
undergoing cystic degeneration. Sometimes when these neo- 
plasms break down in this way they may so block the lymphatics 
with necrotic material that no further extension of the growth 
occurs, and removal of the local focus may enable the patient 
to go years without a recurrence. 

[Inverted U-shaped skin incision in the right groin.] 
The incision goes clear down to the cribriform fascia at the 
distal extremity of the wound. We cut down to the aponeurosis 
of the rectus and external oblique, being careful not to compress 
the tumor at all. I am cutting wide of the tumor. There is 
the aponeurosis of the external obhque. I shall clean away 
everything above the aponeurosis down to Poupart's ligament. 



954 CLINICS OF JOHN B. MURPHY 

I am blocking the lymphatics, you see, by this method of pro- 
cedure. There are the vas and the cord vessels standing out. 
They are not involved, apparently, in the neoplasm, and we must 
separate them carefully from it. There is the inguinal lymphatic 
tract passing down over Poupart's ligament to the femoral 
lymphatic tract to the position where the lymphatics go in at the 
saphenous opening. 

This tumor mass passes beneath Poupart's ligament into the 
deep chain of glands. Therefore, I must divide the hgament 
transversely to continue my dissection. Now, I come down to 
the femoral vessels and I must carefully avoid incising them. 
Now we are down at the base of the growth. There is no longer 
any question in my mind as to what the tumor is. It is easy 
now to tell from its gross appearance that it is a secondary car- 
cinoma. You do not need the pathologist's report now to know 
that. I am going to leave the center of the wound wide open for 
a:-ray treatment. There is no visible tumor left there now. 
Yesterday's diagnosis is confirmed by today's findings. 

The pathologist reports that the frozen section shows an 
epithelioma of the penis. That is correct. Now the whole 
picture is clear. This is a very instructive case, because although 
the intern's errors in the history threw doubt on our diagnosis, 
yet by following the physical signs closely we were able to come 
to the correct conclusion — that the growth was malignant. It 
is an advantage to examine one's cases and get the correct mental 
picture before you turn them loose on the intern. That part of 
the story which most suggested the malignancy was that the 
growth recurred after the first and also after the secondary 
cauterization. So far as the life of the patient is concerned, this 
affection will terminate it sooner or later, notwithstanding our 
x-raiy treatment and everything else we shall do. The femoral 
vessels are not involved nor is the deep lymphatic zone. If 
these structures were involved, we should have had to continue 
our dissection up to the renal vein in order to be certain of excis- 
ing all the infected glands. 

Let the record show that there was a large cystic and solid 
carcinoma metastasis situated in and above the cribriform fascia 
and in the adjacent lymph-glands. 



CARCINOMA OF THE CORONA PENIS 955 

There is the femoral artery. That is a 5 per cent, solution of 
carbolic acid applied to inhibit the growth of any cells which may 
have escaped into the field and are lying free. We shall put some 
nosophen gauze here in the middle of the wound to catch the 
wound secretion. We shall start the a;-ray treatment tomorrow. 

When the carcinoma commences on the corona penis, you 
often have this condition present. The corona is where the 
growth commenced in this man; then it extended over to the pre- 
puce and kept spreading slowly in the proximal direction. Just 
as soon as the tumor extends on to the prepuce, the patient may 
get the lymphatic manifestations. So long as it remains confined 
to the corona lymphatic manifestations are rare, because the 
abundant lymphatic supply of the penis extends just to the corona, 
the lymph- vessels of the glans being few and small. Just as soon 
as the growth reached beyond the corona in this patient he began 
to show the manifestations of metastasis in his groin. 

Carcinoma of the penis, of which epithelioma is by far the 
most frequent variety, makes up about 3 per cent, of all carcino- 
mata in the male, according to most statistics. 

What its ultimate mortality is I cannot state in figures. At 
least it is very high, largely, I believe, because the patients do 
not seek the surgeon's aid until the vascular portions of the penis 
have already been encroached upon by the growth. Of course, 
as soon as the regional lymph-glands are involved, the prognosis 
becomes gloomy indeed. 

For those who are interested in the subject of the pathology 
and the spread of carcinoma of the penis I should like to recom- 
mend a classic article, that of H. Kiittner, entitled ''Ueber das 
Pehiscarcinom, " etc., in v. Bruns' Beitrdge zur klinischen Chirurgie 
for 1900, vol. xxvi, pp. 1-79. This careful study of the subject, 
based on 60 cases from the author's own clinic, has formed the 
basis of most of the text-book accoimts of the disease written 
since that time. 

Pathologist's Report {Dr. Zeit).— The penis removed at opera- 
tion shows a squamous-cell carcinoma of the glans; and the ex- 
cised lymph-glands of the groin show extensive metastases of the 
same cell type. 



956 CLINICS OF JOHN B. MURPHY 

[Note. — The wound on the penis healed by primary in- 
tention. The infected wound in his groin was left partly open 
for x-Tsy treatment, which is still going on at the present time, 
May 8, 19 14. — Ed.] 



I 



FECAL FISTULA 



fflSTORY 

The patient, a young married woman aged twenty-three 
years, entered the hospital with the following history: There is no 
tuberculosis in her family. Her mother died of carcinoma of the 
uterus one year ago (in 19 13) . She has had no past illness of any 
significance, excepting an operation for peritonitis in February, 
1 9 14. Menstruation began at the age of thirteen, and is usually 
of four days' duration; the patient uses three or four napkins a 
day and suffers no pain. Occasionally the periods have been 
somewhat irregular, coming on two or three days before due, and 
at other times two or three days after due. She has been mar- 
ried three years and has one child, thirteen months old. She 
has had one miscarriage, which occurred about January 13, 19 14; 
to it the patient ascribes her present trouble. 

About five days after this miscarriage she had some chilly 
sensations, some fever, and headache. She was taken to the 
hospital and the uterus cureted. She returned home and went 
to bed, remaining there for about two weeks, during which time 
the headache continued, and, she thinks, the fever also. At the 
end of the two weeks she began to suffer severe pain in the 
right lower quadrant of the abdomen. She then had high fever, 
tenderness over the right lower quadrant, and throbbing pain. 
The doctor who was called told her she had "blood poisoning," 
and that she would probably have to have an operation. The 
high temperature lasted about one week, then returned to normal, 
and after it had been normal for a week she was operated. The 
date of the operation was February 27, 1914. She thinks the 
surgeons took out the right ovary, tube, and appendix. A 
drainage-tube was inserted and pus drained from two separate 
openings in the line of incision. One opening continued to drain 

957 



958 CLINICS OF JOHN B. MURPHY 

pus until it closed, six weeks after the operation. The other sinus 
began draining fecal material after the operation, and has con- 
tinued to do so up to the present time. She has repeatedly 
noticed berry seeds coming from this sinus, and, therefore, feels 
certain of the fecal origin of the discharge. 

COMMENTS AND OPERATION 

Dr. Murphy (June 19, 1914): How was the miscarriage 
produced? 

Intern: She says it was induced. 

Dr. Murphy: By what? 

Intern: She would not tell me. 

Dr. Murphy: It was done with a catheter. Put that pomt 
in the history. She did not divulge to me whether she or some 
one else did it, but that is a matter of relative indifference, so far 
as our task is concerned. The important fact for us to know is 
that the deed was done with a catheter; and that seems to be 
the instrument usually employed in these cases, whether the 
patient wields it or the midwife or the doctor. How soon after 
the operation did fecal matter conmience to come out of the 
drainage opening? 

Intern: I do not know, doctor; the history does not state. 

Dr. Murphy: But it should state. Did it appear on the 
next day or on the second day or the third day, or did it take ten 
days or two weeks for the fistula to develop? Was it the se- 
quence of the surgical procedure or was it a sequence of an ul- 
cerative process in the bowel? That is the information which 
one wants in this case and that is what the history should show. 
We asked her that same question at the office, and she told us 
that the fecal flow began on the third day after the operation. 
Then we knew that the surgeon was probably not to blame: 
that it was the pelvic infection which caused an area of necrosis 
in the bowel. 

Those of you visiting doctors who were kind enough to stay 
with us the other day during the tedious ordeal of just such an- 
other case may not be so ready to accept the same kind of a dose 
again today. The operation was irksome , and very monotonous, 



FECAL FISTULA 959 

but its result has been sufficiently gratifying to more than com- 
pensate us for the effort. The patient's condition is splendid. 
Her pulse is 100 and her temperature 99.4° F. this morning. You 
will remember the appalling dissection we had to make, the many 
sinuses present, and the peritoneum wide open to infection. Do 
you also remember the scheme we followed out? To it our grat- 
ifying success and the absence of infection today are due. We 
shall work according to the same plan again today — first plugging 
up the sinuses, then cutting around them, excising the cicatricial 
tissue in the abdominal wall, and thus protecting the field of opera- 
tion — ^including the peritoneal cavity — from fecal matter. That 
is always the plan of campaign which we follow in the operative 
management of these cases. 

The patient's history is a fairly typical one of an infection 
following an induced abortion and treated by curetment. The 
average curetment is done almost always with a sharp instrument; 
and a sharp curet abrades the surface of the uterine mucosa, 
opening up the lymphatic spaces of the submucosa and muscularis, 
and simultaneously inoculating them with infectious material. 
Brisk infection frequently sets in, and with that infection comes 
first the chill and then the rapid rise of temperature. 

When the infection passes out along the lymphatics into the 
cellular tissue of the broad ligament, it usually forms an abscess 
there which extends along the tube. This abscess, if not opened 
by the surgeon, may open spontaneously into the peritoneum, 
bowel, or bladder. It may burrow rather extensively subperi- 
toneally, and is not infrequently complicated with thrombosis 
of the adjacent vessels and a pelvic lymphangitis. 

[Dr. Murphy stuffed up the fistula's cutaneous opening with 
a strip of gauze packed in as tightly as possible. A circular skin 
incision circumscribing the opening, and then a little dissection, 
freed the end of the fistula, so that a volsellum clamp could be 
applied to it tightly, closing it and preventing leakage from the 
sinus during the operation. The cutaneous incision was ex- 
tended straight upward parallel to the median line of the ab- 
domen, with the aim of making the peritoneal opening eventually 
paramedian also, and thus protecting the two incisions, after 
closure of the wound, with the rectus muscle.— Ed.] 



960 CLINICS OF JOHN B. MURPHY 

I am going through the aponeurosis of the rectus muscle and 
endeavoring to separate the rectus fibers from the scar tissue and 
displace them outward from my line of incision. Now we have 
the muscle-fibers all on the outer side. [Dissects out the fistula 
further toward the peritoneal cavity, wraps it in gauze, and puts 
on a clamp to hold it.] That takes care of that infective material. 
[Dissects carefully downward, hunting for the peritoneum. Finds 
it, picks it up with tissue forceps, and opens it cautiously on the 
slant.] I am fortunate in finding that parietal peritoneum so 
quickly, free from adhesions. [Opens the peritoneum widely, 
tampons off the free peritoneal space, and begins to isolate the 
fistula and its attached loops of bowel preparatory to bringing 
them out on to the abdominal wall.] There are many loops of 
intestine united here to this fistulous tract. The same scheme 
which we followed the other day we shall follow now. We must 
go all aroimd the fistula, with its adherent bowel, encircle the 
adhesions, and isolate the entire mass. We are gradually working 
around the point of fixation of the mass to the abdominal wall, 
so as to get the affected intestine free from the surrounding 
sound loops of bowel. That is the first and all-important pro- 
cedure in every type of fecal fistula operation. Here is a sus- 
picious-looking object. It is difficult to say whether it is the 
granulation tissue of the sinus or the mucosa of an embedded 
coil of intestine. [Dissects it out.] It is evidently a granulating 
sinus. I am trying to keep the line of cleavage between sound 
and diseased bowel here in view all the time. 

In getting this mass of scar tissue, sinus, and attached in- 
testines free from their surroundings, it is very important for the 
operator not to get lost in the extensive dissection which is often- 
times necessary. It is all the easier to lose one's bearings be- 
cause of the difficulty in recognizing anatomic landmarks here 
when displaced, as they often are, and when changed in appear- 
ance as the result of old inflammatory processes. In this pelvic 
dissection which we are making our chief difficulty is in getting 
and keeping our bearings as we proceed. Here, at last, is a 
structure which appears to be the urinary bladder. It is. It i> 
the first landmark which we have found. It should be easier to 



FECAL FISTULA 961 

find others now. [Dissects further.] Now we have found the 
uterus and are gradually freeing it of adhesions. Here is the 
stump of the right tube. The salpingectomy was performed at 
the previous operation. 

Here is the intestine which was involved. We now have it all 
loosened from its pelvic adhesions. There is not much danger 
of this patient developing a peritonitis, either pelvic or general, 
because she has had so much inflammation already in her lower 
peritoneal cavity that the lymph-spaces must be well coffer- 
dammed. [Finally frees the fistula with the involved intestine 
from its intraperitoneal attachments and brings the whole mass 
out on the surface of the abdomen. It is well isolated from the 
peritoneal cavity by towels and tampons. Then, loop by loop, 
the intestine, which is adherent to the fistulous tract, but does 
not open into it, is freed, and the raw surfaces thus produced are 
covered by infolding or by approximation to adjacent loops.] 
Here is a communication between the bowel and the fistula. I 
am going to get between that and this other fistulous tract be- 
fore I open either of them. [Isolates both. Then shts up one 
sinus until he comes to the opening into the bowel.] One dares 
not put any traction at all on such a connection for fear of making 
a bad tear. It must be dissected loose — not pulled. Let me 
see if I can come up behind this loop of bowel and separate it 
from the other direction. These coils are all matted together 
on one side as well as on the other. It is not a matter of great 
choice from which direction the attack be made. Here is one 
coil which is involved in the wreck of another. Whether there 
is still another opening or not from the bowel into this sinus I do 
not yet know. I must first try to isolate it further. Here is an- 
other coil which comes into it from the side and is very closely 
adherent to the sinus. V/hether it, too, opens into the common 
cloaca in the way I mentioned yesterday we shall soon find out. 
We appear to have a second sinus coming up here to the common 
suppuration point. We must free that, too. [As he frees the 
second sinus it is seen to join with the first to form a common 
cloaca.] See the line of cleavage ! There is the common cloaca. 
Here is a pocket of granulation tissue close to the junction. 
VOL. in — 61 



962 CLINICS OF JOHN B. MURPHY 

[Continues the dissection and frees a third opening into the com- 
mon cloaca.] Finally, you see, we have arrived at still another 
one. Let us see if this third opening goes through into the bowel. 
Yes, it is patent. We have, therefore, three loops of bowel open- 
ing into this common cloaca. That practically clears up our 
problem in this case. Our further procedures now will be purely 
mechanical. I think I told you yesterday about one such patient 
of ours who had 25 perforations in the bowel, all leading into a 
common cloaca. 

[Frees one perforated coil from the sinus and closes the bowel 
opening with two rows of fine catgut sutures.] 

I am just a bit shy about the security of that closure, and I 
shall not take any chances on it. There is no evidence that it 
would leak; but there is a granulating surface there which it 
would be well to cover in. In these cases one always uses cat- 
gut and not linen for the intestinal sutures, because one expects 
suppuration; if one uses linen in the presence of pus, an opera- 
tion for its removal may be necessary before the sinus will close. 

I am tr3dng to get this next coil of intestine free from its 
upper attachment, which does not open into the sinus, and yet 
not free it from its lower attachment, which does so open. Here 
are the cloaca and sinus, you see. I seem to be having as much 
difficulty in distinguishing the proximal and distal ends of these 
loops of gut as the Irishman did in trying to find the front end of 
the elephant. It is very essential that I recognize correctly this 
matter of direction while I am covering over these raw intestinal 
surfaces, because it would not do to approximate two coils side 
by side in opposite directions, and so have peristalsis in one op- 
pose peristalsis in the other. 

We must next determine where the opening is in this coil 
and what is its character. Here is where the end of the loop 
folds on itself. Gradually we have dissected it free from its part 
of the fistulous tract until we now have it clear out of the field. 
(This loop had no opening into the fistula.) We are gradually 
getting along with our task. 

We shall next free this sinus of adhesions. That is clear at 
last, and we have this opening in the bowel well exposed. Here 



FECAL FISTULA 963 

is the scar tissue mass about the sinus which is holding the in- 
testine down to the sinus. We shall excise that. Now we must 
close the opening in the bowel. We are sewing it with a von 
Eiselsberg needle. That is the best needle for intestinal work. 
It is made very gradually increasing in diameter from the point 
to the eye, separating, not tearing, the tissues, and thus avoiding 
subsequent leakage. That is an overlapping side-to-side suture 
which we are making. We are infolding the entire transverse 
peritoneal surface of the coil. That is cicatricial tissue where the 
needle pulls through the bowel with so much difficulty. 

Let the record show that this sinus was closed with two rows 
of iodin catgut. 

Now we come to the next problem — another perforation. 
This last opening in the bowel makes a large wound. Its great- 
est diameter is transverse. It is easy now to recognize how iiii- 
possible it would have been ever to handle such a great defect 
properly with the bowel down below in the pelvis. It was only 
by dislodging the entire mass of fistula and attached coils of 
intestine up here on to the anterior abdominal wall that we be- 
came masters of the situation. This opening in the sigmoid is so 
large that we cannot safely close it, as we did the other two open- 
ings, simply with two fine catgut sutures. We must reenforce 
the closure with a Pagenstecher linen suture. This is the Czerny 
portion of the suture which we put in first. It includes all the 
layers of the intestine and is of Pagenstecher linen and will hold 
firmly. We are placing this first line of sutures in the trans- 
verse diameter of the intestine, so that we can infold the bowel 
as much as possible. We shall not close the lumen of the bowel 
enough by infolding, however, to produce any obstruction. 

Now that the linen suture is in place, we must turn it in and 
bury it with a second suture of catgut. To do so we start be- 
hind this first line of sutures and put in the second row of stitches 
parallel to the long axis of the bowel, like mattress stitches. In 
inserting this second row we endeavor not to get mucosa, but to 
go through the muscularis with our sutures. Next we put in a 
second row of fine catgut stitches to bury the first; and then we 
are practically finished. We have still only to snip away the 
fragments of the sinus from the abdominal wall. 



964 CLINICS OF JOHN B. MURPHY 

That was a nasty job; but, you see, we succeeded in getting 
it completed in fairly good shape. 

Let the record show that we found three intestinal communica- 
tions with the cavity of suppuration: two smaller ones coming 
from coils located low down in the pelvis, and one large opening 
through which came most of the feces poured out before the 
operation; that all three openings were closed, the two smaller 
ones with double rows of catgut sutures, and the larger one with 
a Czemy stitch of Pagenstecher's linen and two embedding rows 
of catgut. 

Let the record further show that the largest hole was in the 
upper sigmoid; that there was another hole in the sigmoid lower 
down and one in the caput coli. 

[The abdominal wall was then closed in the usual way, leav- 
ing a rubber tube about the diameter of the little finger draining 
the pehis through the lower angle of the wound.] 

We are putting in these figure-of-8 stitches because we rather 
expect the wound to suppurate, and wish to prevent any subse- 
quent gaping of the woimd and visceral prolapse. The layers 
of the wall are all so matted together that we are putting in these 
figures-of-8 as through-and-through stitches, including the peri- 
toneum and the skin, without paying any attention to the ana- 
tomic layers of the wall. 

Let the record show that Sister Ludwina reports the sponges 
counted and correct; that on the first count one sponge was miss- 
ing, but that it was found rolled up in another sponge. Let the 
record further show that the operator made a careful inspection 
of the field to determine that no sponges or instruments were 
left. 

We have lost only one sponge since we started to keep a sys- 
tematic count of them, and that one was never accounted for. 
We do know that it was not left in the patient. We lost one 
other sponge in an operation on the bladder. We reopened the 
bladder at once and demonstrated that it was not there. Then 
we found it later in the hallway just outside the amphitheater. 
It must have stuck to somebody's shoe and thus have been car- 
ried out. 



FECAL FISTULA 965 

We shall put this patient in the sitting-up position as soon 
as she leaves the table, so that all the peritoneal secretions will 
drain into the pelvis. We have inserted a peritoneal rubber tube 
drain to the bottom of the pelvis to take care of the wound prod- 
ucts. 

Let the record show that most of our work here was done along 
the line of peritoneal adhesions and entirely outside of the ab- 
domen, and only a very httle work in the true peritoneal cavity 
after we had first opened the peritoneum to get our bearings. 

Let the record show that the large tube-drain was placed in 
the bottom of Douglas' pouch, extending down behind the 
uterus; that the patient was ordered placed in the sitting posi- 
tion in bed; that nothing is to be given her by mouth at present; 
that she is not to have proctoclysis because of the danger of the 
salt solution working its way through the openings in the colon 
which we have just closed; that if she shows any material shock 
after this operation, which she should not, we shall give her an 
intravenous infusion of normal saline; that if she becomes very 
thirsty, we shall give her saline by hypodermoclysis. 

[June 30, 1914: The wound was resutured. 

July 7, 19 14: The abdominal wound is all healed. 

July 10, 1914: Dressed. Stitches not yet removed. 

There was complete primary union after the second suture.] 



OLD INVERSION FRACTURE OF THE ANKLE. 
OPEN REDUCTION. —EXTRA-ARTICULAR 
NAILING OF THE FRAGMENTS 



HISTORY 

The patient, a twenty-year-old girl, entered the hospital 
June 2, 1914, with the following history: About two years ago 
(July 25, 191 2), while out buggy riding, her horse ran away. 
The patient jumped out of the buggy and fell, striking on her 
right foot, receiving a compound fracture of the ankle. The 
foot was turned inward and backward. The leg and foot were 
put up in a board-splint for two days, and after that a plaster cast 
was applied and kept on for seven weeks. A sinus developed at 
the site of the compounding of the fracture and discharged what 
the doctor told her was serum and not pus. This sinus remained 
open for about three months and then closed. Last July (1913) 
it again opened, discharged the same serum, and closed again 
about last Thanksgiving (1913). She has been using crutches 
until three weeks ago. There has been much pain in the ankle, 
especially at night or after walking about on it. The pain has 
not been so severe during the last two weeks. A skin-graft, 
which was performed last October, healed rapidly. At present 
the patient is incapacitated because the foot, being fixed in an 
inverted position, has developed callosities on its outer side 
which are painful on walking. 

Physical and aj-ray examination of the foot by Dr. Murphy 
on June 2, 19 14, showed that there is a bony ankylosis between 
the astragalus and the tibia; that the bony ankylosis cannot be 
overcome by manipulation; that the best result that can be ob- 
tained is to straighten the leg at the ankle and not increase the 
ankle motion; that the skin over the external malleolus is a mere 
film; that, therefore, the fracture will be necessarily compounded 

967 



^68 CLINICS OF JOHN B. MURPHY 

at the time of the operation, which will somewhat hazard the final 
result and increase the risk to the patient; that these facts have 
been fully explained to the patient, and that she has consented to 
the operation on this basis. 

COMMENTS AND OPERATION 

Dr. Murphy Qune 4, 1914) : Look at the nj-ray plate — that 
tells the story. But it tells an entirely different story from that 
of the average case of Pott's fracture, because this is not an aver- 
age case of Pott's fracture. It is more than a Pott's fracture. 
How did she fall? 

Intern: She does not remember exactly. All she knows is 
that she fell on the right foot. 

Dr. Murphy: Which way did the foot turn? 

Intern: It turned inward and backward. 

Dr. Murphy: That tells the story. The foot turned inward 
and backward. You never get a typical Pott's fracture from an 
inversion trauma. That is where the fundamental error was 
made, both in diagnosis and in treatment, and that is what led to 
this disaster. The history alone should have told the physician 
what was the matter. When the doctor first saw the case he 
could scarcely make out anything at all as to what the conditions 
present were; but the story should have told him that there was 
something else there other than a Pott's fracture, because the 
fracture was caused by inversion. 

Let us see what happened? There was a fracture of the ex- 
ternal malleolus on a level with the articular surface of the tibia. 
It was a fracture of the inner third of the articular surface of the 
tibia, extending upward a distance of two inches, and carrying 
inward all the inner portion of the lower end of the tibia. If that 
had been a Pott's fracture, it would have taken off only the tip 
of the internal malleolus, and if it fractured the tibia at all, it 
would have fractured its outer half and carried that backward 
or upward. The trauma in a Pott's fracture never fractures the 
inner half of the tibia unless it breaks both bones. 

The treatment pursued was the typical treatment for Pott's 
fracture, and thereby resulted this disaster. The typical treat- 






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OLD INVERSION FRACTURE OF THE ANKLE 97 1 

ment for a Pott's fracture is to dress the foot as much inverted 
and as much adducted as possible, with the foot at an acute an- 
gle with the leg. In dressing this foot in superlative adduction 
the foot and the external malleolus have been pulled halfway 
across the articular surface of the tibia and the internal malleolus 
has been dislocated far inward. The inward displacement of the 
lower fragment of the tibia is possibly one-half to three-fourths 
of an inch in extent. 

T was unable to determine definitely, when she was awake, 
whether or not she has a complete bony ankylosis of the ankle- 
joint. Judging from the x-ray picture, I believe she has, and, 
therefore, while I could promise her a straighter limb, I could not 
promise a movable joint. 

Apparently all the internal malleolus must be removed in 
order to bring the foot perfectly plumb with the leg. This is a 
very severe deformity. I am sorry that we have no photograph 
of it, because a good photograph would be valuable in teaching 
how to prevent such a catastrophe in other similar cases. A 
clinic is Hke a mine — it is the day when one expects only the 
usual grubbing that the real treasure is found. The photograph 
would not help us fill the present order, but would be of great 
value for future deKvery. 

All the pressure in walking comes on the outer side of the 
foot. That causes her great pain and discomfort. [Internal 
longitudinal incision.] We shall expose the fracture by making 
our incision to the inner side of the tendon of the tibialis anticus. 
By dissecting downward we expose the line of fracture and the 
ankle-joint. My previous opinion, based largely on the x-ray 
plate, that the ankle is completely ankylosed, is fully verified. 
There is no motion at all in it. It is perfectly solid. That will 
make our task much more difficult than it would have been with 
a few fibrous adhesions and some motion still present. The 
ankylosis is already of two years' standing. 

We shall try to preserve the internal malleolus which we 
have freed, but must excise the piece of bone which Hes between 
the malleolus and the ankle-joint. That is the new growth of 
cancellated bone which has filled in the gap produced by the 



972 CLINICS OF JOHN B. MURPHY 

fracture. What little motion we are able to elicit by flexing the 
ankle is all in the tarsal articulation below the ankle. As soon 
as all the fragments of new bone are removed we shall be able to 
bring the foot around into proper position. The bony fixation 
of the ankle is between the tibia and the astragalus. 

In attacking the fibular side of the fracture we make an ex- 
ternal longitudinal incision and approach the joint by passing be- 
neath the peroneal group of tendons. The upper end of the 
lower fragment of the fractured fibula was displaced inward, 
apparently, on to the articular surface of the tibia. The fibula, 
which has imited in spite of the displacement, must be refractured 
on a level with the articular surface of the tibia, in order to let 
the upper end of the lower fragment slip outward over the articular 
surface of the tibia and come back into proper relation with the 
upper fragment. 

We next have to separate the astragalus from the tibia, to 
which it is united by a bony ankylosis. [The separation is made 
first by outlining it with the chisel and then breaking the bones 
free manually.] Now that the bones and the articulation have 
been freed, the foot can be placed in any desired position. It must 
be placed in slight overcorrection; that is, with the foot turned 
out a little farther than straight. 

The deformity having been reduced, it is necessary to hold 
the bones in the corrected position. For this purpose we shall 
perform the usual extra-articular nailing of the fragments. We 
are driving one wire nail through the internal malleolus up into 
the tibia, and another through the lower fragment of the fibula, 
including the external malleolus, into both the upper fragment of 
the fibula and the tibia. The nails will hold the fragments rigidly 
in position while we are applying the dressings and the wire- 
gauze splint. 

The constrictor was not applied tightly enough to the limb 
at the beginning of the operation. The arterial circulation was 
thus allowed to continue while the venous circulation was blocked. 
Therefore there was more bleeding than if there had been no 
constrictor on at all. The bleeding practically all stopped as 
soon as the constrictor was removed. 



OLD INVERSION FRACTURE OF THE ANKLE 973 

Let the record show that we had much difficulty in freeing 
the astragalus from the tibia because of the complete bony 
ankylosis, of which we informed the patient before the operation; 
that there will be, in all probability, a return of the bony anky- 
losis and a complete fixation of the joint, as we warned the patient ; 
but that we hope to have the foot comparatively straight and in 
line with the leg; that at a second operation we may have to re- 
move some of the prominent portion of the external malleolus, 
but that it must be kept for the present because of the support 
which it gives to the joint; that after the completion of the work 
there was good apposition of the bony surfaces and the foot was 
apparently pliunb with the tibia; that after freeing the astragalus 
on both sides we succeeded in luxating it outward beyond this 
plumb line — that is, we overcorrected the previous deformity of 
the foot. 

The pressure on the circulation in the ankle will be consider- 
able when the edema and swelling develop in these tissues, as 
they always do after such an amount of traumatizing. Have we 
been able in all the manipulating to keep the field sterile? We 
hope so. At least we have not touched even our gloved hands 
to the wound — only metal instruments, sterilized by boiling, 
and dry gauze, sterilized by steam and hot, dry air. 

In every one of these inversion fractures of the ankle we have 
the same difficulty in reducing the deformity and in seeming an 
approximation of the fragments. We have another danger still 
to fear, and that is the increased tension on the circulation when 
this ankle commences to swell. We had one of these cases in 
which it looked as though the patient was going to lose his foot. 
A portion of the great toe and the distal joint of the second toe 
finally sloughed, but still the rest of the foot lived. In straighten- 
ing this patient's foot around into proper position the tension 
became so great on the posterior tibial artery that the circulation 
was shut off. When the swelling developed, the foot turned 
black; but gangrene, in totOj although imminent, was, happily, 
averted. 

Let the record show that on completion of the operation there 
was practically no tension on the skin-flap, so that its circulation 



974 CLINICS OF JOHN B. MURPHY 

is not hazarded; that we had to use no deep ligatures, thus show- 
ing that none of the deeper and important vessels were injured — 
neither the anterior tibial nor the posterior tibial vessels. 

The wound is dressed with gauze moistened with a solution 
of I per cent, carbolic acid in alcohol. The gauze dressing takes 
up all the wound secretions and blood which escape and pre- 
vents them from putrefying. A posterior wire-gauze splint is 
then applied to hold the dressings in place and the foot in its 
corrected position, thus preventing any excess of strain on the 
wire nails. 

[Note. — The wound healed by complete primary union ex- 
cept for a small spot of necrosis over the external nail. The 
latter was accordingly removed, June 30, 19 14. The patient 
is still in bed at the present time, July 6, 19 14. — Ed.] 



INVERSION FRACTURE OF THE ANKLE 
TREATED AS A POTT'S FRACTURE BY 
AN ADDUCTION DRESSING.— CONSEQUENT 
ADDUCTION DEFORMITY.— OPERATIVE 
CORRECTION AND NAILING OF THE 
FRAGMENTS 

HISTORY 

The patient, a young man aged twenty-four years, entered 
the hospital November 25, 19 13, because of a bony deformity 
of the right ankle, slight inversion of the foot, and pain in the 
ankle after walking a considerable distance. 

The patient's present trouble dates back to November i, 191 2, 
when he was thrown violently to the ground while attempting to 
stop a runaway horse and wagon. The wagon- wheel ran over 
the patient's right ankle, across its inner side, the outer side ly- 
ing against the pavement. He was inamediately taken to a hos- 
pital, the ankle was pronounced broken, the foot was manipulated 
without an anesthetic, and the fracture was thought to have been 
put back into place. There was considerable pain in the ankle 
during the ensuing days, and it very soon became swollen and 
discolored. On the third day after the accident an x-tslj picture 
was taken and the patient was told that the condition of the 
ankle was "satisfactory." On the tenth day after the injury, 
the swelling about the ankle having greatly diminished, a cir- 
cular plaster-of-Paris cast was applied, extending from the base 
of the toes to about the middle of the thigh. This cast was left 
on for three weeks, and during this time the patient remained 
in bed. After the cast was removed the patient got up on 
crutches, but did not try to walk on the foot unassisted because 
of the pain caused by any attempt to use it. After using crutches 
a couple of months, during which time he gradually began 

975 



976 CLINICS OF JOHN B. MURPHY 

to put weight on the leg, he was able to walk fairly well, but 
always had some pain in the ankle while doing so. Gradually he 
noticed that he was walking more and more on the outer side of 
the foot, which, in the course of time, became turned somewhat 
inward. After this observation he used a cane in walking, and 
has continued to do so up to the present time. He has had lo 
or 12 x-ray pictures taken to determine, if possible, the cause of 
the disabihty and its course, whether for better or worse. For a 
considerable time he wore a board-splint strapped on the inner 
side of his leg, in order to overcome the inversion of the foot. 
He was told by doctors that the cause of his disability was a con- 
siderable amount of callus at the site of the fracture, which in the 
course of time would be absorbed. 

COMMENTS AND OPERATION 
Dr. Murphy (November 28, 1913): Now we have this 
mighty unpleasant case to handle. The doctor who originally 
treated the case evidently thought that it was an eversion 
fracture — a Pottos — and so treated it, whereas in reality it was 
an inversion fracture. The break was more complicated than 
an ordinary Pott's fracture. Besides the transverse fracture 
of the external malleolus at the level of the articular surface, 
there was also an oblique fracture of the lower end of the tibia, 
involving the inner four-fifths of the lower articular surface of 
the tibia and extending upward and inward for two and a half 
inches, as well as a fracture of both malleoli. The ic-ray shows, 
too, that the upper border of the astragalus is not level. This 
fracture was dressed in the direction in which a typical Pott's 
fracture should be dressed, namely, in superlative adduction, 
and that was the cause of the subsequent deformity; for this 
was not a Pott's fracture but an inversion fracture, and should 
not have been treated as a typical Pott's. As the result of the 
adduction dressing, the internal malleolar fragment was dis- 
placed inward and upward along the inner side of the tibia; and 
the lower articular surface of the tibia, which should contact 
with the astragalus, now runs upward toward the inner side 
instead of horizontally, partly because there was an oblique 




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INVERSION FRACTURE OF ANKLE 979 

fracture across the lower end of the tibia involving its articular 
surface, which should have been dressed with the foot straight 
or in sHght eversion. When the ankle was dressed in superlative 
adduction, there was too much displacement inward of the lower 
fragment of the fibula, and, consequently, the fragments failed 
to unite because of the faulty apposition. The patient's ankle 
is now turned inward and he walks on the outer side of the fifth 
metatarsal bone. His ankle is still painful and he walks with a 
limp. His is not an easy case to remedy, and we have had our 
troubles figuring out a procedure which promises success. I 
think we must bring the lower tibial fragment downward and 
outward and fasten it there. We must elevate the external 
malleolus and reunite it to the fibula, if possible. The internal 
malleolar fragment must likewise be reunited to the tibia. If 
one runs a horizontal line through the a:-ray picture of this ankle 
at the level of the joint, one sees well the deviation from the 
normal. This horizontal fine should He parallel with the lower 
articular surface of the tibia, but, instead, it forms an acute angle 
with the articular surface because of the faulty position of the 
joint structures. 

We told this man that we probably should not be able to 
restore flexion in his ankle, but that we could give him a foot 
which would come plumb with the ground, and would carry his 
weight securely and without pain. The reason we cannot re- 
store his flexion is because there has been a forward luxation of 
the astragalus. We probably cannot altogether overcome that 
luxation, but we hope to reHeve him of the pain which it con- 
stantly causes him. I stated at the outset that this was not a 
genuine Pott's fracture, but an inversion fracture. Let us see 
what are the elements of a true Pott's fracture: 

First: It is always an abduction lesion, that is, it is always 
caused by an injury which produces an abduction of the foot. 

Second: There is a fracture of the fibula always; and that 
fracture of the fibula may occur, as it did here, on a level with 
the articular surface of the tibia, or it may occur anywhere above 
that level, usually not over two or two and a half mches above, 
and is usually accompanied by a displacement of the lower 
fragment. 



980 CLINICS OF JOHN B. MURPHY 

Third: There is a laceration of the interosseous ligament. 

Fourth: There is a fracture of a greater or lesser portion of 
the tibia, or of the internal malleolus, or of the internal lateral 
ligament. 

These are the anatomic elements of the lesion. Occurring, 
as it does, as an abduction injury, one readily sees why the fibula 
breaks first. It is on the fibula that the first strain of abduction 
comes. The reason the fibula breaks is because the strength of 
the interosseous ligament is such that it does not permit the 
fibula to separate from the tibia; and the fibula fractures before 
the ligament tears. But as soon as the fibula has been broken 
and the tip of the malleolus displaced outward, the outer upper 
angle of the astragalus slips up between the fibula and the tibia 
and splits the interosseous hgament like a wedge, so that there is 
a laceration of the interosseous ligament always present in an 
aversion fracture, where the fibula has been broken above the 
articular surface of the tibia. If the violence of the injury car- 
ries the process still further, the internal lateral ligament, the 
internal malleolus, or even a large portion of the lower end of the 
tibia may be broken ofiF; and, in injuries of the severest grade, 
the upper fragment of the tibia may be pushed through the skin, 
compounding the fracture. 

This is a class of cases that we do not particularly like. We 
often wish we could foist them on some one else. They are not 
nice cases, as a rule, either to treat or to meet in the years after 
treatment. They usually have the hammer out for their first 
doctor, and may love their second no better. We have one such 
patient who suffered a gangrene of the foot from an operation of 
this kind. The gangrene was only partial, but he lost the ter- 
minal joint of his great toe. He was suffering from an old back- 
ward luxation of the foot on the ankle following a transverse 
fracture of the posterior lip of the tibia. When we brought the 
foot back into place the tension on the posterior tibial artery 
was so great that the circulation in the foot was shut off. 

[Holds up the patient's foot toward the clinic] 

See the curve that this ankle now has (marked inversion)! 
The foot was dressed in too great inversion. That dcfonnity 



INVERSION FRACTURE OE ANKLE 98 1 

cannot occur after an ordinary Pott's fracture no matter what 
the dressing. [Makes a longitudinal incision over the external 
malleolus and completes the exposure of the site of fracture by 
dissection.] Here is the enormous callus which has formed as the 
result of the fracture of the fibula. There is the articular surface 
of the lower end of the tibia. Here is the former line of fracture 
of the fibula, almost on a level with the articular surface of the 
ankle. With a curved chisel we are cutting away the excessive 
fibular callus and freeing the external malleolus. Now that it is 
freed we must expose the internal malleolus. This is the diffi- 
cult one to manage. [Makes a longitudinal incision over the 
internal malleolus and frees the malleolus by dissection.] This 
is a much harder proposition than the management of the ex- 
ternal malleolus. When one first looks at that internal malleolus, 
the reduction of its displacement appears to be an easy proposi- 
tion to handle; but in reaHty it is far from easy. If this were 
merely a simple fracture of the internal malleolus, the problem 
would not be difficult. It is the combination of the fracture of 
the malleolus with a fracture of the articular surface of the tibia 
which makes our task a serious one. We are opening on to the 
articular surface of the tibia. We must take out enough of that 
tibial callus to let the internal malleolus and its attached articular 
fragment come downward and outward into place. [Uses the 
Jones wrench to swing the foot outward.] Now we have it and 
are masters of the situation. Without that Jones instnmient 
we should have had very serious difficulty in bringing the frag- 
ments into position. We shall now insert the nails. [Drives 
two wire nails through the internal malleolus up into the shaft 
of the tibia, another through the lower end of the upper fibular 
fragment into the tibia, and a fourth through the lower fibular 
fragment into the tibia.] I will just cut off the head of this nail 
(the posterior nail driven through the internal malleolus) from 
the outside, so that I can drive it a little further into the bone 
and keep it from becoming exposed through the skin incision. 

That was a difficult situation to handle. We refractured 
the external malleolus exactly where it was fractured before; but 
we reset it at the correct angle. It stayed in position of itself 



982 CLINICS OF JOHN B. MURPHY 

just where it was. We inserted the wire nails, nevertheless, to 
insure the permanency of our result. 

Let the record show that both the malleoli and the articular 
surface of the joint were accurately exposed; that the bones 
were refractured and the fragments restored to the normal posi- 
tion; that, in fact, we overcorrected the deformity by producing 
some hyperabduction of the foot, which was accomplished with 
the aid of the Jones wrench. 

[The skin incisions were then closed with continuous sutures 
of horsehair after the soft tissues and Hgaments had been united 
with catgut to take the tension entirely off the skin.] 

We were masters of that situation once we had the tibia cor- 
rectly refractured. You can see that we are going to have a 
favorable outcome. This man will get a much better result 
than we promised him if he gets through without an infection, as 
we hope. That will be a nice outcome of an ugly condition. [A 
copious dressing and a circular plaster-of-Paris bandage over it 
were then applied. The plaster cast was cut lengthwise up its 
anterior surface.] 

Notice that we aim never to put on a completely circular 
bandage or cast. If we do use a solid circular dressing, we always 
split it along one side before sending the patient back to bed. 
We have a well-foimded fear of ischemic paralysis. 

Let the record show that we first freed and exposed the line 
of fracture of the external malleolus; that we then divided the 
external malleolus, making the incision crescent-shaped with the 
round chisel, so that the lower fragment of the divided fibula 
could be rotated outward or inward, as necessary; that after the 
division of the external malleolus was completed we refractured 
the internal malleolus and the external line of tibial fracture, ex- 
tending to the articular surface; that we then excised a V-shaped 
piece from the tibia at the upper end of the internal malleolus, 
which included the malleolus and a little more, and tliat division 
permitted the malleolus to come downward and outward into 
proper position; that we put on the Jones wrench and swung 
the foot outward, bringing the external surface of the astragalus 
into articulation with the inner surface of the fibula, so tliat the 




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INVERSION FRACTURE OF ANKLE 985 

foot remained in slight eversion a little overcorrected; that after 
the forcible correction of the deformity two nails were placed on 
each side of the ankle to hold the fragments in position; that the 
limb was then as perfect in conformation as a normal limb — 
perfectly straight except for the slight eversion of overcorrection. 

We shall elevate this foot immediately on the patient's re- 
turn to bed; otherwise edema of the foot is likely to develop 
very quickly. 

REMOVAL OF THE NAILS 

Dr. Murphy (January 15, 19 14): We are going to take out 
the nails today because they have irritated the skin somewhat 
and can now be felt through the skin. [Through two small 
openings, one on each side of the ankle, the four nails were re- 
moved. A Uttle thick material trickled slowly out after two of 
them.] See the discharge which comes out from the site of the 
nails. It is in all probability perfectly sterile because the patient 
has had no fever at any time and the wound has remained closed. 
From now on the patient will not walk as he did when he came 
to us, — on the outside of the foot, — ^but, as he should, on the sole 
of his foot. One never has the kind of a gait which this patient 
had following a Pott's fracture. That was the gait of an inversion 
fracture which, because of a surgeon's mistaken diagnosis, was 
dressed in inversion. Look at the conformation of that foot. 
See how perfectly plmnb it is with the Hmb. There is a little 
granulation tissue around the nails. That is the reaction of the 
tissues to a foreign body and occurs irrespective of its location. 
The tissues loosen up the foreign body and also soften it, when 
softening is possible. When it is not exposed, if it be aseptic, 
its presence is a matter of relative indifference if not too large. 
We are not closing the nail wounds entirely, you notice. We 
are leaving them open where the heads of the nails lay. 

Let the record show that two nails were removed from the 
outer side and two from the inner side of the joint. Let the 
record further show that after the removal of the two nails from 
the outer side of the joint there was some escape of a pus-Kke 
material, notwithstanding the fact that this man at no time has 
had any temperature; that after the removal of the posterior 



986 CLINICS OF JOHN B. MURPHY 

nail from the inner side of the joint there was also an escape of 
some thick material like pus; that there was a direct communica- 
tion between the posterior nail on the inner side and the two nail 
openings on the outer side of the joint, apparently through the 
medium of a cavity in the tibial diaphysis (see x-ray plate) ; that 
the anterior inner naU appeared not to communicate with the 
common cavity; that after the removal of the upper outer nail 
there was an escape of blood rather than of pus. 

That statement shows what may occasionally happen with 
nails as foreign bodies in the tissues. None of those nails com- 
municated with the joint at all, and the joint itself is entirely 
free from any secondary changes. 

[Note (May 5, 1914). — The patient now walks with the limb 
perfectly plumb. He has from 70 to 80 per cent, of the normal 
range of flexion and extension in the ankle. — ^Ed.] 



OLD INVERSION FRACTURE OF THE LEFT 
ANKLE TREATED AS A POTT'S FRACTURE. 
CONSEQUENT BAD DEFORMITY.— OPEN 
REDUCTION AND NAILING 



HISTORY 

The patient, a seventeen-year-old youth, entered the hos- 
pital December 14, 19 13, complaining of weakness in his left 
ankle. His present illness dates back two and one-half years, in 
191 1, when the patient jumped from a height of eight feet, catch- 
ing his foot in a swing, and fell so that in striking the ground 
there was produced a marked inversion of the left foot. There 
was immediate pain in the left ankle, greatly exaggerated on 
pressure, so that the patient could not walk and had to be carried 
home. A doctor was called, and he pronounced the injury a 
fracture of the ankle. The leg was put up in a splint for one 
week, followed by a plaster cast, which was left on for six weeks 
with the foot in an adducted position. The cast extended from 
the toes up the leg to just below the knee. After the cast was 
applied the patient was allowed to use crutches, but not to bear 
any weight on the foot. He continued to use crutches for three 
weeks after the cast was removed. The ankle was then stiff 
and lame and it was difficult for some time for the patient to 
walk unassisted. 

In the spring of 19 12 the patient sHpped and again turned his 
left foot in under him. A doctor treated the injury as a sprain 
and the patient used crutches for one week. 

In the spring of 1913 the patient again sprained his left ankle, 
the foot turning in and under him. This time he used crutches 
for two weeks. 

Last October (1913), while playing football, the left foot 
again was turned forcibly in. The patient used crutches for 

987 



988 CLINICS OF JOHN B. MURPHY 

two days because his ankle was too painful to step on. On last 
Thursday evening (December 11, 19 13) his left foot slipped over 
the edge of the curbstone, as he stepped on it, and he heard 
something snap as the foot struck the gutter. He fell to his 
knees. Since then the left ankle has been sore and stiff. On 
Friday it was swollen. 

Examination on Tuesday, December 16, 1913, showed the 
internal malleolus broken off and displaced upward; the foot lies 
in inversion. 

COMMENTS AND OPERATION 

Dr. Murphy (December 17, 1913): Here is a case of a sup- 
posed Pott's fracture, which was not a Pott's fracture, which is 
always an eversion fracture, but an inversion fracture. It was 
dressed in the superlative adduction position (proper for a Pott's 
fracture, but exactly wrong for an inversion fracture), with 
the regular result — a complete failure. The patient's internal 
malleolus now lies three-fourths of an inch higher than his ex- 
ternal malleolus, because of the displacement caused by the 
faulty dressing. When the patient walks, his foot constantly 
turns in. The injury also broke off a piece of bone from the 
inner portion of the articular surface of the tibia, together with 
the internal malleolus. What must we do to give this patient a 
good functional result? We must bring down into proper posi- 
tion that displaced portion of the articular surface of the tibia 
with the attached malleolus. The left foot in walking always 
turns in because there is nothing to support the internal surface 
of the astragalus against the downward thrust of the body on the 
inner side of the tibia. We must return the malleolus, with the 
attached tibial articular surface, to its proper place and fix it 
there securely. The malleolus must come well down along the 
inner side of the astragalus. 

[Dr. Murphy made a longitudinal incision over the inner side 
of the left ankle along the internal malleolus. Retracting tlie 
cut skin edges, the malleolus came into view and was freed from 
its surrounding soft parts, including the capsule of the joint.J 

That is the capsule of the ankle which I am freeing from the 




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OLD INVERSION FRACTURE OF LEFT ANKLE 99I 

malleolus. The fibrous capsule of the joint comes out over the 
bone. There is the old Hne of fracture of the malleolus. Here is 
the tendon of the tibialis posticus muscle as it comes down behind 
the malleolus with the tendon of the flexor longus digitorum. 
One can see from the a;-ray charts of the circulation about the 
ankle that the blood-supply to this region is ample. As we are 
dissecting here, the Httle spurters seem to come from everywhere. 
I want the wound kept wiped dry, so that I can get my bearings 
as to just where the articular surface of the tibia lies. The 
articular surface of that internal malleolus seems to fit right over 
the spot for which I am searching. There it is at last. It was 
much displaced upward. 

[Dr. Murphy, with the artist's chisel, refractured the internal 
malleolus and the attached fragment of the lower articular 
surface of the tibia, making a V-shaped cut in the inner side of 
the tibia. He then displaced the malleolus downward for about 
three-fourths of an inch in the groove thus produced. The in- 
ternal malleolus, fitting accurately, like a wedge, into this groove, 
from which it was raised by the chisel, was fastened still more 
firmly in place by a tenpenny wire nail driven through the 
malleolus into the shaft of the tibia.] 

We shall insert one wire nail to hold the malleolus in the 
position to which we have brought it. We thus have made a 
new mortise for the astragalus, so deep that the astragalus can- 
not slip out on either side. 

This case is a fair example of this promising new line of frac- 
ture work of ours — the management of fractures near joints by 
single or double nailing. We are trying to advance and improve 
this technic and are very much interested in the method just now. 
Most of these joint fractures we fasten with a single nail, first 
drilling in the bone a hole just big enough to admit the nail, and 
then driving in the nail. We avoid compounding the fracture 
by using only very small skin incisions. This is the practice 
which all surgeons are coming to, I believe, in the very near 
future, in the primary treatment of a great percentage of joint 
fractures, as well as in these late cases. In the discussion of this 
subject in the Surgical Section of the American Medical Associa- 



992 CLINICS OF JOHN B. MURPHY 

don at Minneapolis last year most of the surgeons who testified 
stated that they have been getting satisfactory results in the 
treatment of fractures near joints without the use of this method. 
All one has to do to convince himself of the desirability of this 
technic is to stay here for a month or two and see the failures of 
the ordinary treatment of these cases which come to us for relief. 
Our success is regular. Good functional results must continue 
to follow in the train of good anatomic results. 

Visiting Doctor: Did the nail lacerate the articular surface 
anywhere during its insertion? 

Dr. Murphy: No, the nail did not go through the articular 
surface at all. Our extra-articular, non-bloody nailing of frac- 
tures firmly fixes the fragments in pretty nearly every case with- 
out compounding the fracture or opening the joint. I am now 
having a "drill-nail" and "drill-screw" made, which I can insert 
into the bone as a drill and then clip off flush with the surface 
when it has been driven in far enough to hold the fragments 
together. This "drill-nail" shortens and simplifies the proced- 
ure, and makes success even a little more certain than with the 
wire nail. 

Let the record show that with the chisel we freed the internal 
malleolus well over on to the articular surface of the tibia and 
for a distance of one and three-fourths inches above the articular 
surface, cutting out with the artist's chisel a V-shaped piece of 
bone, together with the internal malleolus; that we then dis- 
placed the malleolus downward and chipped off the protruding 
inner part of this fragment at the articular level of the tibia 
where it was highest; that we then straightened this inner 
malleolar fragment back into position in the groove prepared 
for it, pushed it downward three-fourths of an inch, and secured 
it in its new position with a single nail. 

[Note. — ^The wound healed by complete primary union. The 
patient went home at the end of about six weeks on crutches. 
No further report to date (September lo, 19 14). — Ed.] 



OLD POTT'S FRACTURE.— INTERNAL MAL- 
LEOLUS BROKEN OFF AND ROTATED, PRO- 
DUCING NON-UNION.— OPEN REDUCTION 
AND NAILING 



HISTORY 
The patient, a woman aged twenty-nine years, entered the 
hospital with the following history: On Christmas Eve, 1913, 
she went riding in a buggy. The horse became frightened and 
ran away. The buggy was overturned, throwing the patient 
out. She struck on her right foot. When she tried to rise she 
noticed that she could not stand on or move her right foot, over 
which she had lost control. She does not know whether the 
buggy ran over the limb or not. She does not remember whether 
the foot was inverted or everted by the accident. She was taken 
to a hospital and the foot put in a splint for ten days with an ice- 
bag over the ankle. On January i, 1914, the foot and leg were 
put in a cast and kept there for six weeks. She began walking 
with the aid of a crutch about March ist, two weeks after the cast 
was removed; but it was painful to bear weight on the right 
foot, and, therefore, since then she has worn a leg-brace. There 
is also eversion of the foot when she steps on it without the 
brace. There is not much pain at present. 

COMMENTS AND OPERATION 
Dr. Murphy (June 9, 1914) : Here is an x-ray which is instruc- 
tive. (See Figs. 288 and 289 .) I think this is the second case of its 
kind that I have had. They are the only two cases I know of. 
One I had many years ago — away back in 1886 — in a young man. 
The case was of very much importance to me, for the man was of 
importance to the world at large. His horse ran away and he 
was thrown out of the wagon. He suffered a Pott's fracture, 

VOL. Ill — 63 993 



994 CLINICS OF JOHN B. MURPHY 

with a separation and rotation of the internal malleolus and a 
consequent failure of union. 

Now, then, here is just such another case which has come 
into our hands. This patient, too, had a Pott's fracture. It 
was dressed in the usual way by one of our Chicago colleagues, 
with perfect adduction and turning in of the foot. As a sequence 
of that dressing she has obtained a splendid union of the fibula 
with only a sUght bowing in. She has obtained an exceptionally 
good union of her tibiofibular ligament, which is the all-important 
factor in obtaining a good functional result after a Pott's fracture; 
but there is a failure of union with a rotation of the internal 
malleolus. You can see it beautifully in that ic-ray picture 
taken of the foot dressed in the classic way. The dressing pro- 
duced an almost perfect result in every particular over which 
the doctor had control. Over the matter of union, however, 
we have practically no control beyond the simple and well-known 
measures which favor but do not make certain bony fusion. 
Whether the bone fragments reunite or not when they are 
placed in apposition with one another is a matter with which 
the doctor usually has little or nothing to do. All he can do 
with certainty is to make the apposition correct. He cannot 
greatly influence bone metabolism. We know from the surgical 
teachings of the last two years and from our clinical records here 
of many fractures dressed by us and by others that with the very 
best coaptation and the very best apposition of the fragments 
there will occasionally be an absence of osteogenesis in the injured 
bone. That is one of the considerations which has led me in the 
recent numbers of the Clinics to write so much about the neces- 
sity of avoiding too firm a fixation of the limb in dressing frac- 
tures of the shaft of any of the long bones; that a fracture in 
the shaft of a long bone, if absolutely fixed by very rigid im- 
mobilization, such as a plaster cast, nailing or wiring, or a bone- 
plate gives, lacks enough stimulation at the broken ends to 
produce active osteogenesis in them; and that there con- 
sequently is a failure of union. That, I believe, is why the 
mechanical fixation by open o{>eration is playing such an important 





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Fig, 292. — Same case. Anteroposterior radiogram made twelve weeks after 
operation. The nail, still in situ, already shows slight erosion of the shaft of the 
nail not far from its head and near the old line of fracture of the internal malleolus. 
This erosion appears to be due to the action of body fluids on the nail, the first step 
in the process being oxidation, probably. 



997 




V 




Fig. 293. — Same case. Lateral radiogram matlc twelve weeks after ojioraiion. 
The bone atrophy, while still i)resent, appears to have undergone some rcstilutio ad 
inUgram since the previous radiograms were made. 



998 



OLD pott's fracture 999 

role in producing the present great frequency of post-operative 
non-unions. 

[Dr. Murphy demonstrates the photographs and oj-ray plates 
of another patient. See pp. 977-985 of this issue of the Clinics.] 

Here is another case of a Pott's fracture with a bad result. 
It was given the typical Pott's dressing in the superlative ad- 
duction position; but the fracture was not a typical Pott's: it 
was a fracture of the internal malleolus. That man got a bad 
result from his doctor's dressing because, in addition to the 
breaking off of the internal malleolus, he also had a splitting up- 
ward of the tibia. When he came to us he was walking on the 
outer side of his foot. We got a good result out of it ultimately, 
as you see, by operative measures. 

In this case today the result of the dressing, I should say, 
is superlatively good, because a plumb line through the center of 
the tibia would pass through the middle of the astragalus. I 
think that limb is not one-hundredth part of an inch out of plumb. 
It is perfectly adjusted. Here in this other case, however 
[demonstrating again the it:-ray plates], the plumb line did not 
pass through the middle of the astragalus at all. It was thrown 
away over to the inner side. That was a bad result, for the foot 
was greatly everted as the consequence of the internal malleolus 
being broken off. We replaced the malleolus by open operation, 
put the limb in a plumb line, drove in two nails to fix the bones 
in the new position, and achieved this splendid result. [Shows 
patient's photographs.] It is not enough to demonstrate that 
our performance was mechanically correct; we must show, too, 
that we produced a serviceable leg for the patient. 

This is not a pleasant task which we have before us now. 
All these operations about the ankle-joint are much more dijE- 
cult than the similar operations about the knee. Some of the 
visitors present today may remember the case we operated on 
Thursday (June 4th), and what a very severe task it was to get 
that foot around into proper position. The anatomic and func- 
tional relationships with which we have to deal in the ankle-joint 
are more compKcated and hence more difficult to manage than 



lOOO CLINICS OF JOHN B. MURPHY 

in the knee-joint; and the functional stresses which the ankle 
must withstand are more severe than those put upon the knee. 

[Dr. Murphy made a longitudinal incision over the internal 
malleolus, carrying the cut immediately down to the bone. The 
edges of the incision were drawn apart by retractors and the soft 
parts and attachments separated from the internal malleolus and 
adjacent tibia by blunt dissection.] 

There is a line of fibrous union between the separated mal- 
leolus and the tibia which I must free so as to be able to rotate 
the malleolus, and to get it back into proper approximation with 
the tibia. [Continues dissecting.] Now the malleolus has come 
around into position beautifully, so that the line of separation is 
only barely apparent. 

[Dr. Murphy then fixed the malleolus in place with an eight- 
penny wire nail driven through it up into the tibia.] 

One can scarcely see the line of division now. The nail 
extends well into the tibia through the malleolus. [The soft parts 
were then drawn back over the seat of fracture and the skin 
wound closed.] I am putting in three tacking stitches of catgut 
to unite the soft parts and take the tension off the skin, so that 
there will be no danger of our cutaneous horsehair approximation 
sutures breaking. We were careful in performing this operation 
not to touch anything that came into contact with the wound. 
That is the key to successful bone work. In putting in the buried 
knots of catgut my gloved hands did not come in contact with 
the wound, nor did any portion of the catgut that touched my 
hand come in contact with the wound. 

We leave the nail in situ indefinitely in most of these cases. 
Ultimately, we shall probably take out this nail, but not for a 
long time, — probably three or four months, — by which time the 
patient will have a firm bony union between the fragments and no 
longer need the fixation and support which the nail provides. 

Let the record show that there was a complete failure of bony 
union between the internal malleolus and the tibia; that the 
malleolus had rotated on its longitudinal axis as a pivot, thus 
turning away its fractured surface from the fractured surface of 
the tibia. 



lODI 

When this old fracture has firmly united we shall probably 
elongate and transplant the tendo Achillis so as to rotate the 
ankle around inward and overcome the existing eversion. That 
correction should not be attempted now. It is a matter of only 
a few minutes to carry out, but it requires a solid ankle to with- 
stand the necessary manipulations. 

Let the record show that the upper or fracture surface of the 
internal malleolus had been rotated outward by the traction of 
the soft parts on it and that I had to free the soft parts in order 
to let the malleolus turn in; that after freeing it and freshening 
its broken surface and the adjacent surface of the tibia we suc- 
ceeded in securing an accurate apposition of the fragments with 
a single nail. So accurate, in fact, was it that one could scarcely 
see where the line of separation had been when we were through 
with its fixation; that there was an eight-penny nail driven up 
through the malleolar fragment into the shaft of the tibia and 
fairly well buried under the soft parts; that a Hght plaster cast 
was applied; that three catgut stitches were used to reunite the 
cut soft parts, chiefly connective tissue, before the skin sutures 
were inserted; that the skin was closed with horsehair. 

[Note. — The wound healed by complete primary union. 
The patient left the hospital on July 14, 19 14. Her condition 
was good and there were already firm bony imion of the fragments 
and no swelling of the foot. The motion in the ankle was only 
shghtly limited, and will result eventually in perfect mobility. 
She was allowed to walk alone on her ankle with the aid of 
crutches at the end of eleven weeks. She returned to the hos- 
pital September 2 for passive motion and a:-ray pictures. She 
can now walk without mechanical aid and without pain (Sep- 
tember 14, 19 14). — Ed.] 



REMOVAL OF NAIL FROM THE RIGHT TIBIA 
AND OS CALCIS 



[This case, a spontaneous painless inversion fracture of the 
right ankle in a tabetic patient, followed by the development of 
a Charcot joint, was originally reported in the February, 19 14, 
Clinics, page 12. The foot was originally dislocated inward to 
such an extent that the patient's external malleolus almost rested 
on the ground. The patient could not bear his weight on the 
foot — not because it was painful, but because it gave way under 
him. Dr. Murphy reduced the fracture-dislocation and fastened 
the fragments in their correct position by three wire nails, all 
inserted by the bloodless method, and only one nail passing 
through the ankle-joint — that one which was driven through the 
heel and up through the os calcis into the tibia. After healing 
had occurred, the upper two nails were removed. An attempt 
was made at the same time to remove the lower nail, — that driven 
through the heel, — but the attempt proved unsuccessful because 
of the great firmness with which the nail was engaged in the bone. 
More time was, therefore, allowed to elapse, in order to permit 
lacunar bone absorption to occur around the nail, thus loosening 
it, before making a second attempt at removal. — Ed.] 

Dr. Murphy (June 18, 1914) [Pointing to the x-ray plate]: 
Here is a place where union did not occur between the tibia and 
OS calcis. There is the remaining nail still fastening the tibia 
over the calcaneus. I went in after that nail once before, at the 
1 time I removed the two others, and just could not get it out. 

It was too firmly embedded. Our nail forceps could not budge 
it. There is no bony union between the patient's tibia and his 
astragalus because his astragalus has practically entirely dis- 
appeared during the course of his trouble. This is a typical 
Charcot joint, its internal structure greatly altered, yet never 
I 1003 



I004 CLDHCS OF JOHN B. MURPHY 

painful, because of the more or less complete regional anesthesia. 
It is this peculiarity about Charcot joints which leads oftentimes 
to unexpectedly unfavorable results after treatment of injuries 
of them or in their vicinity. Such cases often appear to get along 
very nicely following the injury, and seem to give a good immedi- 
ate result; and yet the ultimate result may be highly unsatis- 
factory. In the case of injury to the ankle, for instance, tabetic 
patients may suffer a Pott's fracture and, after treatment with 
the typical adduction plaster-of-Paris dressing, may be discharged 
at the end of five or six weeks apparently completely cured. 
Then the foot commences gradually to evert or invert, absorp- 
tion of the bone in pressure areas starts in, and, finally, the 
patient comes back at the end of three months with a beastly 
result — a typical, well-advanced Charcot joint; and, too often, 
he attempts to lay the blame for this outcome at the door of his 
surgeon. 

It is the regional anesthesia or hypesthesia in the lower ex- 
tremities of these patients which is to blame for the bad result. 
Faulty dressings, lack of padding, overcorrection, and cramped 
positions produce no discomfort in the anesthetic joints of tabetics 
and, therefore, remain uncorrected or are not corrected sufficiently 
early. Moreover, a tabetic often will walk unconcernedly about 
on a sprained or even a broken ankle, thus piling Pelion on Ossa 
in the matter of adding injury to injury. That it is the regional 
anesthesia which lies back of the development of these Charcot 
joints rather than vague and mystical "trophic changes," that 
handy cloak for etiologic ignorance, may be seen from the fact 
that Charcot joints occur only in anesthetic or hypesthetic areas, 
in the knees and ankles in tabes, and in the elbows and wrists in 
syringomyelia. Whoever saw a Charcot joint in a tabetic elbow, 
wrist, or shoulder unless that patient had a tabes cervicalis 
rather than a tabes dorsalis? 

[Dr. Murphy points again to the x-Ta.y plate.l 

There is the nail I could not pull out a few weeks ago. Now 

all I have to do is to open the door, as it were, and let it run out. 

It is just the same nail. The only change was in the bone. 

What has happened? An osteoporosis has been set up around 




loos 




Fig. 296. — Same case before correction. lig. 29 7. —Same case before correction. 



XO06 




Fig. 298. — Same case. Lateral radiogram made eight and a half months 
after Dr. Murphy's correction and naiUng, and just before extraction of the remain- 
ing nail. The two upper nails were removed about four months before this radio- 
gram was made. Note the disappearance of the exuberant callus of the previous 
radiograms and the clearer outlines to the bones, meaning that less bone regenera- 
tion is going on because less bone destruction is taking place now that the previous 
static deformity has been overcome. 



1007 



REMOVAL OF NAIL FROM RIGHT TIBIA AND OS CALCIS lOOQ 

that nail, perhaps with a little hematogenous infection added, 
months and months after the original operation, when the place 
seemed entirely healed. [Makes an incision over the head of the 
nail, grasps it with an artery forceps, and the nail slides out of the 
heel without effort on Dr. Murphy's part.] That is just what I 
told you — that this nail was already loose. That shows what 
happens around a large foreign body long left in the tissue. It 
must be about four months now since I tried in vain to take out 
this same nail. 

Let the record show that since the previous operation bone 
absorption has continued in the astragalus until practically none 
of the articular and posterior portions of the astragalus now is 
left; that the nail was removed without difficulty and that no 
pus exuded down along the tract to the surface. The loosening 
up of the nail, therefore, was due merely to lacunar bone ab- 
sorption about the nail as about any foreign body long lying in 
bone, and not to any long latent or recently developed local 
infection. 

[Note. — The patient left the hospital immediately after the 
operation and has not returned since then for observation 
(September lo, 19 14). — Ed.] 



VOL. m — 64 



A RECENT REPORT FROM AN OLD CASE OF 
KNEE ARTHROPLASTY 



Dr. Murphy (June 13, 19 14) : I had a very pleasant surprise 
yesterday. A nurse from Sydney, Australia, in coming through 
California, met a patient of mine who was operated October 28, 
191 1, for a bony ankylosis of the knee; and the patient sent me 
these pictures by the nurse (see the accompanying illustrations). 

This patient had originally a very bad bony ankylosis of the 
knee. She was one of the cases in which we established a com- 
plete rotation of the patella in performing the arthroplasty in 
order surely to prevent subsequent recurrence of the ankylosis. 
We "turned the woolly side in," so to speak, in dealing with the 
patella. On looking at the x-ray plate of the ankylosed knee 
one sees that the knee was ankylosed at almost a right angle. 
In "turning the patella turtle" we reversed the aponeurosis of 
the patella so that it rested against the femur. Here we have, 
for comparison, the radiograms and photographs before and 
after operation. This young lady, the nurse, brought me these 
last pictures, which were made on June i, 19 14. The patient 
was operated October 28, 191 1. The nurse states that she had 
known the patient for two or three days before she found out 
that she had had an operation on her knee. If the patient had 
not told her, she would not have known it. The patient is a very- 
bashful woman. She went out in the alley behind her home to 
have these last pictures taken by a girl friend rather than go 
to a professional photographer. They are not the pictures of an 
artist, but they show well the final result of our operation. In 
one picture the patient is holding up the operated leg voluntarily 
without any artificial support. She has the power of flexion to 
at least a right angle. In this second picture she is standing 
straight and one can scarcely tell which knee is the operated one, 



IOI2 



CLINICS OF JOHN B. MURPHY 



the conformation is so perfect. That, I believe, is one of the 
chief reasons why we have had good results in this Hne of work. 
We endeavor to restore the normal conformation of the joint, so 
far as possible, in performing the arthroplasty. The patient is 
about equally knock-kneed in both knees, but walks perfectly. 
Tfiis is a case where the flexible joint is the result of an operative 
rotation of the patella. Such rotation of the patella insures 
freedom against return of the ankylosis, because the patellar 
aponeurosis will not imite to the femur. The operation is tech- 
nically difficult, except where the ankylosis is at an acute angle. 
We had a little caries occur at the tip of one patella after turning 
it in such an operation. We have never had a separation of the 
ligamentum patellae or of the quadriceps tendon. 








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IOI4 





Fig. 303. — Arthroplasty for bony ankylosis of the right knee. Anteroposte- 
rior radiogram (shortly) after operation. An approximately normal conformation 
has been given the joint, although there is, naturally, a little ''Hpping" and blurr- 
ing of the bone margins. The muscle sutures of phosphor-bronze wire show in 
this radiogram. 



1015 




ioi6 




Fig. 307. — Arthroplasty for bony ankylosis of the right knee. Lateral radio- 
gram made nearly three years after the operation. The patella is seen in profile, 
" turned turtle," and has, perhaps, taken on a more normal contour during the 
passing years. The muscle sutures of phosphor-bronze wire show in this radiogram 
and have produced no irritation or inconvenience in all the years they have been in 
place. Note entire absence of any "atrophy of disuse" in the bone. 



1017 





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The Following Series of Drawings Illustrates the Steps in the Operation. 

Arthroplasty of the Knee for Bon-y Ankylosis, Several Cases of 

Which have been Reported Hitherto in the Clinics. 






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1036 



The Following Series of Drawings Illustrates the Steps in the Opera- 
tion, Arthroplasty of the Elbow for Complete Bony Ankylosis 
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sion, Cases of which have been Heretofore Reported in the Clinics. 




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1034 



HYPERTROPHY OF THE MIDDLE LOBE OF 
THE PROSTATE.— URINARY RETENTION.— 
PROSTATECTOMY 



HISTORY 

The patient, a married man aged sixty-three years, entered 
the hospital with the following history: For the past fifteen years 
he has had, at intervals, attacks of frequent urination accom- 
panied by more or less difficulty in passing the urine. These 
attacks lasted usually about a week until some three years ago, 
when their duration increased to between three weeks and a 
month. These more prolonged attacks have been gradually 
occurring more frequently. Finally, six months ago, — in No- 
vember, 1 9 13, — the difficulty in passing urine and in starting the 
flow became continuous, and frequent urination became persis- 
tent. The patient had to get up three or four times during the 
night to urinate. For the past two months he has also had fre- 
quent burning pains in the bladder. He has never passed blood 
or pus in either the urine or the feces. He has never had any 
chills or fever. He has gained somewhat in weight in the last few 
months, he thinks. He was catheterized three times six weeks 
ago in order to evacuate the acutely retained urine. 

COMMENTS AND OPERATION 
Dr. Murphy (April 22, 19 14): His first catheterization be- 
came necessary six weeks ago. The interval between micturi- 
tions at night has gradually become less and less over a mmiber of 
years. His prostate even now is not greatly enlarged, although 
somewhat larger than normal. Recently he has come face to 
face for the first time with the real danger of his prostatic disease, 
namely, catheterization. He has had, judging by the history, 
transient infections of the urethra from time to time, but they 

1035 



1036 CLINICS OF JOHN B. MURPHY 

did not produce sufficient inflammatory edema in the prostatic 
urethra to make catheterization necessary until six weeks ago. 
After three periods of acute retention necessitating catheteriza- 
tion six weeks ago, he has succeeded again in reestablishing vol- 
untary urination. The doctor who passed the catheter took 
every precaution at the time to avoid an infection of the urethra 
or bladder, and because he was catheterized only three times he 
has not acquired a urinary infection. If it had been 23 times or 
53 times that the catheter was used, the chances are that he would 
now have a bladder infection. With repeated catheterization a 
traumatic urethritis is produced, on top of which a bacterial 
saprophytic infection is easily implanted. The patient is a 
physician, and he has kept a careful watch on the development of 
his affection. I think he has acted more wisely in the matter 
than most doctors do. He realized that when his enlarged pros- 
tate had arrived at the catheter stage, it was high time to adopt 
operative measures, and that it was highly dangerous to delay 
further until a suppurative cystitis with a suppurative urethritis, 
or a pyelonephritis was engrafted on the prostatic obstruction, 
constantly threatening him with death from sepsis and gravely 
complicating any subsequent operation on the prostate. 

When I wrote my first article on the prostate, I insisted that 
the day on which the patient started to use the catheter was the 
day on which he should prepare for prostatectomy. I am happy 
to say that both the profession and the people are rapidly coming 
to that same conclusion. The results that have been obtained in 
such cases by the removal of the prostate fully justify that posi- 
tion. The average immediate mortality in prostatectomy is now 
down to about 2 per cent., including all the conditions for which 
the operation is performed. The mortality of prostatectomy 
undertaken after the establishment of catheter life is already very 
high and is on the increase. It is not likely that any series of pros- 
tatectomy cases will show a mortality much below 2 per cent., 
for the operations are performed on patients advanced in years, 
whose vital capacity is not at the maximum, and who are fre- 
quently sufferers from serious conditions, of which chronic ne- 
phritis, myocarditis, and arteriosclerosis arc not the least. The 



HYPERTROPHY OF MTODLE LOBE OF PROSTATE IO37 

patients with such affections have a minimal resistance against 
infections of all kinds, both local and general. Post-operative 
pneumonia is frequent, and ulceration and necrosis in the neigh- 
borhood of the bladder opening are sometimes severe and ex- 
tensive, and may spread to the surrounding fascial spaces. The 
patients with advanced arteriosclerosis have particularly little 
resistance against infection. 

Let us next consider the type of operation to be advised. 
When we started operating on enlarged prostates, we were ad- 
vising the perineal route, and recommended the U-shaped in- 
cision. We had fairly good results with that method, but they 
were not at all as uniformly satisfactory by that perineal route as 
our present results are by the suprapubic route. The technic of 
the perineal procedure, no matter how slowly and carefully it is 
carried out, involves a greater manipulation of tissues over a 
more extensive and difficult anatomic field than does the supra- 
pubic technic. In operating for any lesion on the neck of the 
bladder, one needs to bear in mind that in operations from above 
one opens the bladder through a relatively simple route — through 
its wall. By the perineal route, however, one opens the bladder 
through a highly complex anatomic zone, from the direction of 
its natural opening, it is true, but by far less simple a path. One 
might com^pare the suprapubic operation with an attempt to 
break into a house through one of its side walls, which is done by 
knocking out a few bricks with a pickax. The perineal operation, 
however, is like an attempt to enter the same house from the 
direction of the front door, but at an angle to it, so that steps, 
porch, and pillars must be cut away before the wall itself can be 
attacked. In entering by the perineal route, one is compelled to 
make just such an oblique approach to the urinary outlet, the 
functional capacity of which, therefore, is likely to be seriously 
interfered with. Since the prostate Hes directly below the 
bladder mucosa, it is not necessary to disturb the parts surround- 
ing it in removing it by the suprapubic route. All that is neces- 
sary is to divide the mucosa with the finger-nail and then peel 
the prostate out of its bed beneath the mucosa. Even with a 
careful and skilful perineal dissection, there are more dangers to 



1038 CLINICS OF JOHN B. MURPHY 

be encountered by the lower route than by the upper. Freer, of 
London, does the suprapubic operation, and he, I believe, is 
more largely responsible for the present general adoption of the 
suprapubic route in removing the prostate than any other single 
surgeon. I remember visiting Freer once and examining the 
great collection of prostates which he keeps in glass cases. His 
earlier published articles did not give one a good idea as to the 
method he uses in taking out a prostate. One of the chief reasons 
why I visited him was to find this out. It was a simple thing 
which he taught me, but one of great importance. I have fol- 
lowed the method ever since. The point is this: Always start 
peeling out the prostate from the upper anterior edge, not the 
lower posterior. It makes a great difference in the ease with 
which the prostate peels out. We always use a sound in the 
urethra as a guide in our dissection. Pass the index-finger in 
along the anterior surface of the sound and tear through the 
vesical mucosa at the upper border of the prostate. One is able 
to peel out the prostate, as a rule, from the vesical mucosa, 
leaving the latter to flap back over the defect. The prostate, 
when removed, includes, of course, the prostatic urethra. This 
procedure is associated with much less danger of injury to the 
neck or bas fond of the bladder than is the dissection from the 
reverse direction. On opening the mucosa, one comes at once 
on the fibrous portion of the prostatic capsule. If one keeps 
carefully within that fibrous portion, the enucleation is made in 
the zone where the vessels are smallest and where they bleed the 
least. The moment one penetrates beyond that zone, one enters 
a vascular network which can be the source of a great hemorrhage 
at the time of operation, and, likewise, after operation. 

I am passing the sound into the bladder as a guide. [Makes 
the usual curved transverse incision above the symphysis.] I 
am keeping as close to the symphysis as possible in carrying on 
this dissection, and, as I approach the bladder-wall, I am dis- 
placing the peritoneum upward and out of the field. Now I can 
feel the tip of the sound. Next we wipe the extra vesical fat ofiF 
the anterior wall of the bladder. The tip of the sound stands up 
in the center of the field, pushing the bladder- wall forward at its 




Fig. 327, — Suprapubic prostatectomy. Step I: The bladder-wall transfixed 
and held up by two linen "anchor" sutures. The incision made in the midline of 
the bladder between the two sutures and over the tip of a sound introduced through 
the urethra and pressed firmly against the anterior bladder-wall. 



1039 



HYPERTROPHY OF Mn)DLE LOBE OF PROSTATE IO4I 

center. (See Fig. 327.) Before opening the bladder we pass the 
so-called "supporting" or ''anchor" stitches through the entire 
musculature of the bladder- wall, one on either side of the promi- 
nence made by the tip of the sound. These stitches enable us to 
maintain control of the bladder all the time during the subsequent 
steps of the operation. The bladder-wall is divided between 
these two stitches over the tip of the sound. 

[Dr. Murphy slips one end of a long rubber tube into the 
bladder opening, and lets the other end hang over the edge of the 
table.] 

We sipnon the urine out with this tube. When the urine is 
drained off we pass this self-retaining retractor into the opening. 
The retractor is to hold the bladder open, so that we can look into 
it and make a thorough inspection, as well as a digital examina- 
tion. 

There are no particular irregularities that I can feel along the 
bladder surface of the prostate (i. e., no cancer nodules). The 
middle lobe is rather conspicuous, and appears to be the cause of 
the obstruction present. 

[Dr. Murphy passes the fore and middle fingers of his left 
hand into the rectum, and with them presses the prostate for- 
ward, making it more accessible to the dissecting finger within 
the bladder.] 

I am endeavoring to make a smooth enucleation of this rather 
firm prostate, using my right forefinger to separate the gland 
from its fibrous capsule. 

[Dr. Murphy promptly completed the enucleation of the 
prostate. Pushing the dislodged gland to one side, he proceeded 
to make a bimanual examination of the operation site — the bed 
of the prostate — for remnants of gland, calcuh, or other anomalies. 
It was found smooth and free from changes. The ensuing hemor- 
rhage consisted of a mild degree of capillary oozing from the 
prostatic capsule. The loosened gland was Hfted from the base 
of the bladder and out of the wound with a pair of gall-stone 
forceps.] 

I always keep my finger in the rectum until the prostate has 
been grasped by the forceps and removed. This was not an easy 
VOL. m — 66 



I042 



CLINICS OF JOHN B. MURPHY 



case to handle. It was a rather difficult one, in fact, because of 
the firmness and relatively small size of the enlarged gland. The 
larger ones are always the easier to take out. We have learned 
that fact from experience. There is practically no bleeding at 
all to be seen in the bladder. Next we examine the bladder, both 




Fig. 328. — Suprapubic prostatectomy. Step II: Two fingers of left hand in 
rectum press prostate forward to meet index-finger of right hand, which l^egins the 
dissection at the upper margin of the gland. The sound in the urethra is drawn 
out until only its tip remains still within the bladder. 

with the finger and with the eye, for other lesions, especially 
stones. Many times one finds calculi in the bladder in these old 
prostate cases, especially when there has been frequent or long- 
standing obstruction. Phosphate stones are the most frequent 
variety. There are no calculi or other pathologic changes to be 



HYPERTROPHY OF Mn)DLE LOBE OF PROSTATE IO43 

found, and no roughening or laceration of the edges of the pros- 
tatic wound. 

In closing the bladder we use interrupted sutures, which lie 
entirely outside the bladder mucosa, being passed so as to include 
only the muscular layer of the bladder-wall. 




Fig. 329— Suprapubic prostatectomy. Step III: The prostate, including the 
prostatic urethra, now dissected free, lies at the base of the bladder and is removed 
by forceps. 

Let the record show that the prostatic enlargement was 
located practically entirely on the right side of the gland; that 
there was also a teat-like projection in the midline posteriorly, 
and that it was this projection which overhung the internal ure- 
thral orifice, that was the principal factor, probably, in his ob- 
struction. 



I044 CLESnCS OF JOHN B. MURPHY 

In resuturing the bladder-wall the anchor stitches which I 
inserted before opening the bladder are of great importance. 
In picking up the cut edges of the bladder we keep these original 
tacking sutures in view all the time. That is the advantage of 
having them there. We are never at a loss to know just where 
we are and what we are suturing. They are invaluable as land- 
marks, as one realizes best when attempting such an operation 
without their help. 

[Completely closes the bladder incision with a double layer 
of Lembert stitches, being particularly careful not to pass any 
of the stitches through the vesical mucosa.] 

Now that the bladder wound is closed, we withdraw these 
two anchor stitches. 

[The muscle and fascia of the abdominal wall were then sut- 
ured with a running suture of catgut, and the skin with silkworm- 
gut figure-of-8 sutures, which also pick up the rectus fascia, and 
with horsehair.] 

A permanent retention catheter will be immediately inserted 
into the bladder through the urethra. A small gutta-percha 
drain will be inserted into the abdominal wall down to the line of 
bladder sutures. The last catgut stitch through the bladder- 
wall was utilized to fasten the bladder-wall up to the sheath of 
the rectus, and thus keep the bladder from falling back and mak- 
ing a dead space which might fill with wound secretion, or with 
urine in case a leak should develop in our line of suture. That 
dead space is always a serious menace after bladder operations, 
and a phlegmon originating in it is a dangerous complication, 
because of the ease with which it spreads through the fascial spaces 
of the pelvis. 

Let the record show that the prostate was completely enu- 
cleated; that the slight enlargement of the middle lobe was tlic 
important factor in the production of the urinary obstruction; 
that the greatest degree of enlargement was in the right lobe, but 
that the greatest obstruction was, as we suggested before opera- 
tion, from the teat-shaped, overhanging middle lobe. 

This gutta-percha drain goes down to the bladder, but not 
into it. We no longer use permanent suprapubic drainage of 



HYPERTROPHY OF MH)DLE LOBE OF PROSTATE IO45 

the bladder in cases like the present, with practically no hemor- 
rhage from the operation site, and with no accompanying urinary 
infection. Formerly we used to drain all our cases from above, 
but we believe it merely retarded the progress of cases like the 
present one. 

We attach this retention catheter to the penis, so that there 
will not be the slightest traction on it. It is fastened just over 
the foreskin. If the adhesive plaster fixation dressing is applied 
too tightly, a swelling of the foreskin may develop. We believe 
that in this class of cases we obtain better results by draining 
through a retention catheter in the urethra than through a sup- 
rapubic opening. Where we have more profuse hemorrhage we 
insert a suprapubic rubber tube in the bladder and drain through 
the operation wound as well as the urethra. 

This was the kind of prostate that one can take out readily 
through the perineum. In my original paper on the subject I 
stated that a small prostate was particularly favorable for re- 
moval through the perineum. It is not the taking out of them 
which we fear. Like death, it is the after-effects, not the pro- 
cedure itself, of which we are afraid, and the evil sequence of the 
perineal operation is loss of control of the sphincter. There is 
much better urinary control with the suprapubic operation. 

In the first paper on prostatectomy written by Freer he said 
that he retained always the prostatic mucosa, both urethral and 
vesical. Because of this statement we went to the dissecting- 
room and tried to take out the prostate of cadavers and save the 
prostatic mucosa. It could not be done. We satisfied ourselves 
thoroughly on that point. In the very next article which Freer 
wrote he called attention to the extent of the urethra, about half 
an inch, that could be removed at prostatectomy without inter- 
fering with bladder control! From this statement we drew the 
natural deduction that he had come to the same conclusion as we. 

This patient was fortunate in being a doctor and taking alarm 
in time. He did not wait until catheterization had produced 
serious urinary infection before submitting to operation. He 
will reap his reward by having an easy, short, and uneventful 
convalescence and a permanent cure. Will he also be potent? 



1046 CLINICS OF JOHN B. MURPHY 

Probably yes — at least, as much so as the average man of sixty- 
three years. 

[Note. — Owing to a blood-clot lodging in the end of the 
catheter, the catheter had to be removed and a new one 
inserted at the end of twenty-four hours. No further trouble 
was experienced. The catheter was removed at the end of about 
a week and the patient left the hospital at the end of two weeks. 
The suprapubic wound healed by complete primary intention, 
the gutta-percha drain being removed at the end of twenty-four 
hours. After the permanent catheter was removed, the patient 
had apparently normal control of urination. He had no pain on 
urination, no difficulty in starting the stream, and no difficulty 
in retaining the normal amount of urine in the bladder. At the 
time of discharge his urine was perfectly clear, and the micro- 
scope showed no increase in the number of leukocytes. The 
patient ran no fever at any time. Catheterization showed no 
residual urine. Since leaving the hospital the patient has made 
no subsequent report to us, and we presume, therefore, that he b 
enjoying his usual good health. — Ed.] 



IMPERFORATE ANUS 



HISTORY 

The patient, a female infant aged seven weeks, was brought 
to the hospital May i8, 1914, with the following history: The 
mother states that the baby was born at a normal labor and that 
it had bowel movements every day for the first two weeks of life. 
Since then, that is, during the last five weeks, it has been increas- 
ingly difficult to obtain bowel movements from the patient. On 
Friday, May 15, 19 14, the baby had not had a bowel movement 
for nine days. Since then she has only had one slight movement. 
At the end of the first two weeks of difficult defecation, and after 
the bowels had refused to move at all for two or three days, the 
mother examined the baby and discovered that it had no anus. 
The doctor who was at once consulted examined the infant and 
stated that the feces came through the vagina. The baby 
appears to be otherwise normal in every way. 

COMMENTS AND OPERATION 

Dr. Murphy (May 18, 19 14): That is all there is to the 
history — brief, but to the point. Now, then, doctor, where did 
the feces make their exit, and how often did the feces pass? 

Intern: I do not know. The mother told me at first that 
the baby never had a bowel movement. 

Dr. Murphy: How old is the baby? 

Intern: Seven weeks. 

Dr. Murphy: Then the baby must have had a bowel move- 
ment or it would be dead. 

Intern: The mother states that it vomited ever3rthing it ate. 

Dr. Murphy: That is not the point. The point is that the 
baby had bowel movements. It has had a bowel movement 
since it came into the hospital. It is well that you asked the 

1047 



1048 CLINICS OF JOHN B. MURPHY 

mother again how many bowel movements the baby had. It is 
seven weeks old now and something must have come through its 
bowel or the baby would be dead by this time. We actually 
know from our own observation that since the baby came here 
she has had a bowel movement, small in amount, it is true, but 
immistakably fecal. The intern's statement is correct that it 
vomited almost everything it swallowed. 

On examination the vulva is found a little red and congested. 
The hymen is a little larger than usual, and the opening in it is 
wider than normal. There is an indentation, not deep enough 
to call a depression, about the position where the normal anus 
should be. The fecal material which appears comes out through 
the vulvar opening and through the vagina. Nothing comes out 
through the anal indentation. The question that one next asks 
is, Does the fecal stream come through the vagina, or does it come 
through the urethra? What type of congenital anomaly, in 
other words, has she? 

These congenital abnormalities and defects in the develop- 
ment of the genitalia, rectum, and urinary apparatus are divided 
into certain distinct types. Particularly well defined are the 
rectal anomalies. They are: 

First: The undescended rectum, which remains high up in the 
pelvis or abdomen, and fails to come down far enough to become 
a part of the cloaca. 

Second: The properly descended rectum, with total absence 
of an anal depression on the perineum, no effort being made to 
form a proctodeum by an indentation of the skin to meet the 
rectum. 

Third: The rectum, which reaches down almost to the anus, 
with a slight anal depression present on the perineum, indicating 
that the rectum is just within or beneath the skin. 

Fourth: The development of an anus and a considerable 
depression beyond it, with a cutaneous lining, but separated 
from the descending rectum by a shorter or longer interval, or 
connected with it by an impervious fibrous cord. 

Fifth: The rectum in the male may open through the peri- 
neum, through the scrotum, or through the urethra or bladder, 
thus forming a congenital fecal fistula. 



IMPERFORATE ANUS 



1049 




Xi^cTltm opens intb 
prostatic uretAra 



Tectum opens 
into vuli/d. 



T^ectum ending blindtu 
<aT i)dck. or prostate 




Tectum endins blend (y at Rl?c(um aiteict, .. . 

patenor /bmtx of vagina prostate by fibrous cord 



TlecTum atlached to 
post, i/^p/nci/ vault 
ay Tibrous cord 




Ab^sence or- nrorTr^H^nm Proctodeum and rectum not Proctodeum and recTum 

Aosence or procZodasum communicatmff but attached to ^epar^Ted by a Thia membrane 

each other by Tibrou.5 cord 




Tectum opens 
inli) vagina 




X • \R^ctum opena 
into penile urethra 



Fig- 330- — The varieties of imperforate anus. 



1050 CLINICS OF JOHN B. MURPHY 

Sixth: In the female the rectum may open into the vagina, 
or, much less frequently, into the urethra or bladder. One may 
also find the urethra, bladder, and vagina all communicating 
with the rectum, so that urine as well as feces comes out through 
the rectum, so that fecal matter may pass out through the ure- 
thra, and urine mixed with feces pass out through the vagina, or 
through the anus, if the latter be patent. 

We have not yet made an internal examination of the little 
patient, but we shall do so as soon as she is well anesthetized. 
We are considerably aided in analyzing the type of anomaly in 
this case by the statement of the mother that the baby's urine 
comes out perfectly clear. That means that there is no open 
communication between the rectiun and the bladder. That is 
about all the information we have bearing on this subject, 
except that we know there must be a rectovaginal opening, as we 
have already stated. 

[To examine the baby's vagina Dr. Murphy used a small- 
sized Kelly cystoscope, throwing in the light through a head re- 
flector. The vagina was wiped clear of feces by the repeated use 
of cotton on an applicator.] 

There is nothing to be seen in the vagina that looks like an 
opening into the bladder. Nothing comes out of the vagina 
that looks like urine; but fecal material and gas keep bubbling 
up somewhere along the posterior vaginal wall every little while. 
It is the presence of this fistulous opening that has been the life- 
saving feature in this particular case. 

[Dr. Murphy then passed a flexible silver probe through the 
cystoscope and, finally, with its assistance, was able to locate the 
fistula rather high up on the posterior wall of the vagina. The 
probe, when introduced through this opening, ascended a con- 
siderable way without resistance and returned smeared with fecal 
material.] 

Let the record show that the examination of the vagina 
through a Kelly cystoscope revealed no evidence of a vagino- 
vesical opening, but did reveal the presence of the suspected 
rectovaginal fistula on the posterior vaginal wall. The vagina 
seems considerably congested. 



IMPERFORATE ANUS IO51 

[With the aid of the cystoscope Dr. Murphy then passed a 
ureteral catheter through the fistula up into the rectum, and 
then, beside it, he passed a flexible uterine sound so curved that 
its tip turned downward toward the terminal pouch of the rectum. 
It did not come down sufficiently far, however, to be felt from the 
outside, and, therefore, in the ensuing operation considerable 
dissection was necessary before the tip of the probe was located.] 

There is a slight anal depression present here. There is also 
a little hole just inside this depression which looks as though it 
might possibly conununicate with the rectum. [Dr. Murphy 
then tried to follow this opening with a fine silver probe, but was 
imable to find any communication with the rectum. In con- 
tinuing his upward dissection, however, this opening was of some 
value as a guide, and it was in this direction that he proceeded 
and finally located the rectum.] 

Intern: The patient's doctor states that the bowels moved 
once each day for the first two weeks of life ; then went nine days 
without any movement. 

Dr. Murphy: Let the record show that we first passed a 
ureteral catheter and then a curved uterine probe alongside it, 
as a guide in our perineal dissection, through the vaginal opening 
into the bowel; that we then opened the perineum from behind, 
using the anal depression as the central point of our dissection, 
and gradually worked upward toward the tip of the uterine probe; 
that we exposed the posterior wall of the rectum; that we then 
exposed the lower end of the rectum, opened it, and divided its 
attachment to the wall of the vagina, closing the vaginal opening 
and the rectal opening separately; that the end of the rectum was 
approximated with catgut sutures to the skin, and the divided 
tissues behind the anus closed with silkworm-gut. 

Let the record show that there were no feces present in the 
lower part of the rectum, that portion lying below the level of 
the rectovaginal fistula. The entire absence of feces in the lower 
rectal pouch was an odd feature of the case, because there was no 
obstruction to their entrance into this wide-open and directly 
adjacent pocket. 

This is the first case of the kind that we have had this year. 



1052 CLINICS OF JOHN B. MURPHY 

It is a condition which occurs in one form or another in every 
10,000 or 12,000 births. For that reason every obstetrician, 
pediatrician, and general practitioner should understand it and be 
prepared to meet it, because it is one of the things that can occur 
in almost any practice. 

This baby had apparently good bowel movements for the first 
two weeks of its Hfe nearly every day, and then they gradually 
became less and less in amount. Then, at last, it was noticed 
that the bowel movements were coming from the vagina, or, at 
least, through the vulvar opening. There was no anal opening 
and only a slight anal depression to be seen. The baby's move- 
ments gradually decreased in amount, so that, finally, for a 
period of nine days it passed no feces at all; but it vomited every- 
thing taken by mouth. What type of ileus was that? A me- 
chanical obstruction without a strangulation, later developing 
into a practically complete obturation ileus, also without a 
strangulation and located at the lower end of the bowel. The 
absence of strangulation explains why that patient could go for 
nine days without a bowel movement and yet survive. If there 
had been a strangulation ileus present, the patient would have 
been dead in a couple of days, or in three days at the most. But 
because there was an opening to the exterior, although small, the 
baby was able now and then to get a little gas and fecal matter 
through to the outside, and that Httle makes the great difference 
between life and death in such cases. For nine days at a stretch 
she passed just a little gas through the vagina and no fecal matter 
at all; but at other times she has also passed a slight amount of 
feces through the vagina. 

Congenital Malformations of the Rectum 

I. Persistence of the original communication of the rectum with 
the cloaca. 
A. Males: 

{a) Ending of the rectum in the urethra at the lower end 
of the verumontanum, beyond the openings of the 
uterus masculinus and ejaculatory ducts. 
(6) Ending in the trigone of the bladder. 
, (c) Ending at the external meatus of the urethra. 



IMPERFORATE ANUS IO53 

(d) Ending at the apex of the prostate. 

(e) Opening into the frenum of the prepuce. 
(/) Opening into the under surface of the penis. 
(g) Opening into the raphe of the scrotum. 

(h) Opening into the raphe of the perineum. 
(i) Two openings: 

1. The proctodeum has grown in and opened into 

the rectum, forming an anus in the usual 
position. 

2. The cloacal orifice is prolonged forward and 

opens into the median raphe of the scrotum 
near the root of the penis. 
B. Females: 

(a) The rectum opens into the navicular fossa of the 
vulvar cleft. 

(b) Opens into the vagina. 

(c) Vulva and clitoris are prolonged to form a urethra, 

and the rectum opens in its floor below the orifice. 

II. Non-development or imperfect development of the post- 

allantoic gut. 

(a) Post-allantoic gut practically non-existent; rectum 
ends blindly at: 

1. Base of prostate. 

2. Upper level of vagina. 

(b) Post-allantoic gut may grow backward imperfectly 
and become separated from the prostate or vagina. 
It may end as a fibrous cord attached to either — 

(i) the proctodeum, 

(2) the site of normal anus. 

III. Non-development or ill-development of the proctodeum. 

(a) The original membrane separating the proctodeum 
and the post-allantoic gut may partially or com- 
pletely persist. The former condition results in 
a fibrous stricture, the latter in an absolute barrier. 

(b) The proctodeum may be feebly developed or there 
may be no anal depression at all. The nearer the 
rectum lies to the perineum, the better developed 
is the proctodeum; but a well-developed proctodeum 
does not signify a well-developed rectum. 

rV. Congenital narrowing of the anus without complete occlu- 
sion. 

The foregoing chart gives one a fairly good idea of the varieties 
of congenital conditions that can occur with an imperforate anus. 



I054 CLINICS OF JOHN B. MURPHY 

Unless one has in mind a pretty clear idea of the exact anomaly 
present in a given case, and, likewise, a clear mental picture of all 
the possible complications that may be met in handling that 
case, one is not justified in attempting to find the rectum, be- 
cause, as one can readily see, great disaster can come to the 
patient through misguided surgical efforts. I cannot emphasize 
the great frequency of such disasters better than by citing the 
Cripp table, showing the types of operation performed for this 
condition and their results. He collected loo cases, with a 50 
per cent. mortaHty. A 50 per cent, mortality is too great a 
mortality for this condition in the hands of an operator who has 
a clean-cut mental picture of what he expects to do and what it 
is possible for him to find during his exploration in the individual 
case. 

In making the new anus we fixed the rectxmi to the margin of 
the skin at the place where the sphincter muscle seemed to be 
located. We believe we have not interfered so materially with 
the sphincter as to affect its fimctional capacity seriously. If we 
have, the patient will subsequently suffer from incontinence; 
but we hope we have been able to avoid injuring it. We went, 
in our dissection, between the two layers of muscle which make 
up the levator ani and, we believe, we passed between the two 
halves of the sphincter ani. This patient has nm no risk to her 
life in this operation. There is a Httle possibility of an infection 
from above, but not from below. We knew before we started 
that we were going to find the rectum in a fairly definite location, 
close to the posterior wall of the vagina; and with the uterine 
sound we maintained a definite guide to our procedure during the 
entire operation. In operating these cases one must have a 
fairly clean-cut picture of the situation in one's mind before 
making the incision; because, in some cases, one incision may be 
in the abdomen and the other incision on the perineum or else- 
where, and one cannot elongate even in case of dire necessity one 
of the incisions to meet the other. Therefore, the incisions must 
be planned on an accurate knowledge of the conditions present, 
and one cannot make an accurate diagnosis in this line of cases 
without a clear understanding and a definite mental picture of 
all the pathologic conditions which may occur. 



IMPERFORATE ANUS IO55 

SECOND OPERATION 

Dr. Murphy (July 3, 19 14): We let this patient go home 
shortly after the operation, when the rectal wound had healed, as 
it did promptly, and without any complications whatever. We 
thought we had made a good-sized anal opening, and we had; 
but after the patient returned home it began to contract. The 
operation scar was annular, and it tightened up rather rapidly. 
We must dilate it again and put in a rubber tube until it stays 
dilated. We were successful in saving the sphincter, just as we 
hoped. In saving the sphincter, however, we made this annular 
scar about the anus. The anal opening at present appears com- 
pletely closed, but the rectovaginal fistula is still leaking. If we 
get this anal orifice fully open, we believe that the fistula will 
close completely. If the fistula does not close of itself, we can 
still close it by an operation. That rubber tube which we have 
inserted in the anus will be kept in continuously, and the anus 
will soon accommodate itself to it. 

Let the record show that the anal opening, because of the 
annular scar about it, had closed down to pin-point size, and was 
so narrow that it would not admit the small probe; that after 
dilating it a rubber tube was inserted and held in place by the 
dressing; that we put a safety-pin on the tube to keep it from 
shpping up into the rectum. We did not use a silkworm-gut 
stitch to hold in the rubber tube, as we often do in drainage cases, 
because the contraction of the sphincter may pull on the stitch 
and make the stitch cut through muscle and skin. 

[Note. — ^The patient went home the same day and has not 
reported since.] 



THE USE OF RADIUM AND THE a;-RAYS IN 
THE TREATMENT OF CANCER 



A Talk in the Course of Operating on a Case of 
Carcinoma of the Breast 

Visiting Doctor: Do you think the a:-ray is of any value in 
the prevention of a recurrence of a breast carcinoma? 

Dr. Murphy (September 2, 1914) : Yes, I do. Do I know it 
has any advantage? No. Do I think so? Yes. We advise it, 
we order it, and we believe it does some good. Its retarding 
action on the development of a carcinoma is due, we believe, to 
the fact that it is capable of stimulating cicatrization or con- 
nective-tissue formation around the maHgnant cells to the degree 
of strangulating them. On these malignant cells which have 
escaped from the primary focus into the neighboring tissues, we 
believe that the a:-ray has some effect. We use it on practically 
all our carcinoma cases after operation, and we use a relatively 
hard tube in giving the treatments. 

We have not had much experience yet with the Coolidge 
tube, but every present indication points to the conclusion that 
Coolidge's invention is one of the greatest recent advantages in 
x-x2iy engineering and is going to be invaluable to us in the treat- 
ment of deep-lying and inoperable malignant tumors. We never 
use the x-ray on a case as a substitute for an operation. We 
use the x-ray occasionally on inoperable cases. We use it a great 
deal, however, in the hope of preventing recurrence after we have 
removed by operation all the visible tumor. While I was abroad 
this summer I took the opportunity to go into all the details of 
the present status of radium therapy in both the Radium In- 
stitute and the Cancer Hospital in London. The surgeons in 
charge of both of these efficient modern institutions, scientists of 

VOL. Ill — 67 1057 



1058 CLINICS OF JOHN B. MURPHY 

great authority who have attacked the problems of cancer 
treatment from every angle, never speak of radium as a cure for 
deep-seated cancer; that is, they never advise it in any case that 
is still operable. So strongly are they intrenched in this opinion 
— we seize naturally on military terms in these days — that not 
only do they not advise radium in these cases, hut they will not 
administer it to such patients as are still in the operable stage of the 
disease. In other words, they will not be parties to the crime of 
suicide — which a cancer patient commits when he omits know- 
ingly the necessary operation during the curable stage of his 
malady. In the operable varieties of cancer these Londoners be- 
lieve that radium has a strongly inhibitory effect on the growth 
of the carcinoma, and that it materially retards the speed with 
which the tumor destroys the patient; that the patient lives 
longer and lives more comfortably with the radium treatment 
if his is an inoperable case. 

When I was in Leeds, visiting Mr. Moynihan, I saw a large 
inoperable carcinoma of the side of the face just anterior to the 
ear — exactly the type of a case that came to my office yesterday, 
and that I may be able to show you here in clinic within a few 
days. For this patient Mr. Moynihan used not the pure radium, 
but the radium-sensitized material which comes in a little tube 
sealed in glass. He punctures the cancer tissue and plants this 
tube in it. Mr. Moynihan believes that this method is more 
effective in the management of large tumors than the use of the 
pure radium itself. Captain French, who has charge of the 
Radium Institute in London and is a master of the subject of 
radium therapy, holds the same view as Mr. Moynihan. Mr. 
Moynihan told us that this cancer of the face stood out from one- 
half to three-fourths of an inch above the level of the skin when 
the patient began treatment. When we saw him the tumor had 
practically disappeared, and one could tell there had been a lesion 
there only by close examination. The patient had had three 
implantations of radium-sensitized tubes in the growth. I spoke 
about this case to Captain French, and he said, ** Yes, that is just 
what radium will do in the first treatment; but that growth will 
recur, and the next time that the radium is used it will have little 
or no effect on the tumor." 



RADIUM AND THE X-RAY IN CANCER IO59 

That is a sad outlook, but it appears to be the truth of the 
matter. While radium in the primary application may destroy 
the cancer to a great degree and retards its further growth, it does 
not seem to have the same effect on the tumor in subsequent 
appHcations. In reply to my question as to the cause of the 
destructive effect of radium on these malignant growths, Captain 
French stated that its action is that of excessive stimulation of 
the tissues exposed to its action; that it stimulates the cells to 
the degree of necrosis; that it actually cauterizes the surrounding 
neoplasm. Following the death of the tumor tissue comes, in 
its place, an excessive production of connective-tissue cells, which 
tend to strangulate such malignant cells as may have escaped the 
action of the radium. That is the theory of the destructive 
action of radium, as Captain French tells it. 

In cases of inoperable carcinoma of the rectum, radiimi has a 
striking effect. It stops the bleeding, it stops the pain, and it 
stops the tenesmus; it retards the course and spread of the 
disease; but it does not cure. The place where it has the most 
striking effect as a palHative measure is in inoperable carcinoma 
of the uterus. In these cases they implant the sensitized tube 
into the mass of tumor tissue at the cervix. The subsequent 
result looks more nearly Kke that in a case treated by zinc 
chlorid packing, which was brought out by A. Reeves Jackson 
of this city thirty years ago, than anything else with which I am 
familiar. It produces a local necrosis of the tissues, somewhat 
elective toward the cancer, but not entirely elective, because, 
in cases of which we were told in London, there were a number 
of cases of fistula of the bladder, and a similar number of cases 
of fistula of the rectum following its application to the uterus. 
The significance of this fact, I take it, is that the radium necrosis 
extends beyond the limits of the cancer. The subsequent course 
of these cases is that the further development of the growth is 
markedly inhibited and that the type of tumor changes from the 
rapidly fatal medullary form to the slower growing scirrhus. 
Recurrence is inevitable, but death comes relatively slowly in 
the radium-treated cases, and the discomfort caused by the tu- 



1058 CLINICS OF JOHN B. MURPHY 

great authority who have attacked the problems of cancer 
treatment from every angle, never speak of radium as a cure for 
deep-seated cancer; that is, they never advise it in any case that 
is still operable. So strongly are they intrenched in this opinion 
— we seize naturally on military terms in these days — that not 
only do they not advise radium in these cases, hut they will not 
administer it to such patients as are still in the operable stage of the 
disease. In other words, they will not be parties to the crime of 
suicide — which a cancer patient commits when he omits know- 
ingly the necessary operation during the curable stage of his 
malady. In the operable varieties of cancer these Londoners be- 
lieve that radium has a strongly inhibitory effect on the growth 
of the carcinoma, and that it materially retards the speed with 
which the tumor destroys the patient; that the patient lives 
longer and lives more comfortably with the radium treatment 
if his is an inoperable case. 

When I was in Leeds, visiting Mr. Moynihan, I saw a large 
inoperable carcinoma of the side of the face just anterior to the 
ear — exactly the type of a case that came to my office yesterday, 
and that I may be able to show you here in clinic within a few 
days. For this patient Mr. Moynihan used not the pure radium, 
but the radium-sensitized material which comes in a little tube 
sealed in glass. He punctures the cancer tissue and plants this 
tube in it. Mr. Moynihan believes that this method is more 
cfiFective in the management of large tumors than the use of the 
pure radium itself. Captain French, who has charge of the 
Radium Institute in London and is a master of the subject of 
radiiun therapy, holds the same view as Mr. Moynihan. Mr. 
Moynihan told us that this cancer of the face stood out from one- 
half to three-fourths of an inch above the level of the skin when 
the patient began treatment. When we saw him the tumor had 
practically disappeared, and one could tell there had been a lesion 
there only by close examination. The patient had had three 
implantations of radium-sensitized tubes in the growth. I spoke 
about this case to Captain French, and he said, *' Yes, that is just 
what radium will do in the first treatment; but that growth will 
recur, and the next time that the radium is used it will have little 
or no effect on the tumor.'* 



RADIUM AND THE X-RAY IN CANCER IO59 

That is a sad outlook, but it appears to be the truth of the 
matter. While radium in the primary application may destroy 
the cancer to a great degree and retards its further growth, it does 
not seem to have the same effect on the tumor in subsequent 
applications. In reply to my question as to the cause of the 
destructive effect of radium on these malignant growths, Captain 
French stated that its action is that of excessive stimulation of 
the tissues exposed to its action; that it stimulates the cells to 
the degree of necrosis; that it actually cauterizes the surrounding 
neoplasm. Following the death of the tumor tissue comes, in 
its place, an excessive production of connective-tissue cells, which 
tend to strangulate such malignant cells as may have escaped the 
action of the radium. That is the theory of the destructive 
action of radium, as Captain French tells it. 

In cases of inoperable carcinoma of the rectum, radium has a 
striking effect. It stops the bleeding, it stops the pain, and it 
stops the tenesmus; it retards the course and spread of the 
disease; but it does not cure. The place where it has the most 
striking effect as a paUiative measure is in inoperable carcinoma 
of the uterus. In these cases they implant the sensitized tube 
into the mass of tumor tissue at the cervix. The subsequent 
result looks more nearly Kke that in a case treated by zinc 
chlorid packing, which was brought out by A. Reeves Jackson 
of this city thirty years ago, than anything else with which I am 
familiar. It produces a local necrosis of the tissues, somewhat 
elective toward the cancer, but not entirely elective, because, 
in cases of which we were told in London, there were a number 
of cases of fistula of the bladder, and a similar number of cases 
of fistula of the rectum following its application to the uterus. 
The significance of this fact, I take it, is that the radium necrosis 
extends beyond the Kmits of the cancer. The subsequent course 
of these cases is that the further development of the growth is 
markedly inhibited and that the type of tumor changes from the 
rapidly fatal medullary form to the slower growing scirrhus. 
Recurrence is inevitable, but death comes relatively slowly in 
the radium-treated cases, and the discomfort caused by the tu- 



Io6o CLINICS OF JOHN B. MURPHY 

mor is decreased by lessening the discharge from it and dimin- 
ishing the dangers of saprophytic infection and hemorrhage. 

That is about what one may expect from the use of radium 
in columnar-celled adenocarcinoma. In the squamous cancers, 
such as occur in the mouth, they do not advise radium at the 
Institute. They have had just about the same degree of success 
with these cancers as the surgeons. Any one who has had ex- 
perience in operating on mucous membrane carcinomata is very 
happy when these cases go to the other fellow, because he knows 
that the cancer is going to come back, in all probability, and 
terminate fatally, no matter what is done. This opinion of the 
action of radium on mucous membrane cancers is also supported 
by Abbe, of New York, who has had quite an experience along 
this line. Just before I went to Europe this summer a man came 
to me with a carcinoma of the mouth, beginning at the angle of 
the jaw. I sent him to Abbe for radium treatment, but Abbe 
would not treat him; he said it was no use, and sent him back to 
me. Captain French, on exactly the same grounds, refuses to 
treat these cases in the Radimn Institute of London, because he 
knows from his experience that they are certain to terminate 
fatally. 

In the superficial varieties of carcinoma ot the skin, the type 
of carcinoma that has been cured by the application of the ic-ray, 
I think that radium has a more rapid action, is more easily con- 
trolled in its application to small lesions, and its activity can be 
more definitely limited than the ic-rays, and appears to be more 
effective because it is superficial in its action. In the treatment 
of the angiomatous type of birthmarks, radium is a splendidly 
effective therapeutic agent. In the treatment of keloids it is 
also a fine thing. 

That seems to be the present therapeutic position of radium. 
Exactly the same opinion was voiced by the physician in charge 
of the radium section of the London Cancer Institute, a man of 
great experience and high scientific attainments. He showed us 
every possible courtesy, and it is with great regret that I must 
admit his name has escaped me for the moment. He agreed 
entirely with the conclusions of the workers in the Radium 
Institute. 



RADIUM AND THE a'-RAY IN CANCER I061 

We have, therefore, from the use of radium, gained no impor- 
tant additional data for the cure of cancer. We must put the 
radical treatment of cancer back on the same surgical basis where 
it has so long rested. Cancer is a surgical lesion from its very 
beginning. It is at first purely local in its manifestations and 
should be removed at the earUest moment, while it is still a local 
disease. The colossal force of numbers shows in cancer statistics 
that, no matter what our theory as to the nature of the malady, 
a larger percentage of cancer cases remains well when the tumors 
are taken out early than when removed late in the disease. That 
is the present clinical proposition, and it is the clinical standpoint 
in these cases which is all-important. 

That radium is of some advantage to hospitals in the manage- 
ment of inoperable cases of malignant tumors we think is true. 
It is of some advantage in a large city in treating the inoperable 
cases, because these patients prefer to live at home, and, while 
under radium treatment, are able to do so. An operation takes 
them to the hospital. The :t;-ray, properly appKed mth a hard 
tube, gives better results than :r-ray treatment formerly did, 
because we are thus able to prevent practically entirely the 
burning of the skin, and we are able to take out practically all 
the alpha and beta rays. Also, when we are able to eliminate 
the alpha and beta and leave only the gamma rays, the latter 
seem to have greater effect in stimulating the production of con- 
nective tissue around the irritated cancer-cell nests. We hope 
that when the Coolidge tubes are made in greater quantities, 
and their price lowered to meet the means of the many hospitals 
and physicians who now use the a:-rays in treatment, some further 
advance in the treatment of deep-seated, inoperable cancers may 
be made. The CooUdge tube is so constructed that it auto- 
matically eliminates the dangerous and useless alpha and beta 
rays, and produces only the gamma rays. Moreover, it produces 
them in great quantity, for the tube can be run day in and day 
>ut at very high amperages without deteriorating or discoloring 
the tube, and, what is still more important, without altering the 
tension of the tube and the character of the rays produced. 



V 




Dr. John B. Murphy 



Volume III 



THE CLINICS 

OF 

JOHN B. MURPHY 



Number 6 



THE NEW OFFICES OF DR. JOHN B. MURPHY 
AND HIS STAFF 

We have received in the recent past a large number of requests 
for portraits and photographs, as well as for the plan and scope, of 
the new offices which Dr. Murphy and his staff now occupy. With 
the desire of meeting the wishes of the subscribers to the Clinics, 
we secured the consent of Dr. Murphy to make a complete series 




Fig. 331. — Exterior view of office building. 



of photographs of the building and the offices, which we present 
to the readers of the Clinics, feeling assured that the sugges- 
tions arising from them will be of value to physicians elsewhere. 
The building is situated on Calumet Avenue, between 
Twenty-fifth and Twenty-sixth Streets, next door to the Calumet 
Avenue entrance to Mercy Hospital. It is, of course, at Mercy 
Hospital that Dr, Murphy and his staff do all their work. It can 

1063 



be readily understood what a great saving of time is accomplished 
by ha\ing the offices in such close proximity to the hospital. 

As will be seen from 
the plan, all the offices 
are situated on one floor, 
together with the labo- 
ratories, the x-ray room, 
the photographic studio, 
filing-room, etc.; only 
the library and consul- 
tation room for the staff, 
in the front of the build- 
ing, reached by a short 
flight of stairs, are on 
the second floor. All the 
offices open on the main 
center hallway, which 
runs the full depth of 
the building, making the 
arrangement a model 
of practicability. 

It is unnecessary 
to describe the various 
rooms and offices in de- 
tail, as the pictures speak 
for themselves. 

The offices are re- 
plete with everything 
for the comfort and con- 
venience of patient, and, 
as can be seen from the 
pictures, with every fa- 
cility for their examina- 
tion and diagnosis. 

Our readers will re- 
alize the advantage of 
having all branches of a 
busy practitioner's work 
under one roof, all of 
which can be arranged 
without the involvement 
of enormous ex])ense. 

We feel certain that 
our subscribers will wel- 
come our presenting to 
them the views, and the 
amount of space in this 
number of the Clinics given to their presentation. 

1064 





>■ 333- — Entrance hall to offices. 




i^ig- 334-— Main hallway on both sides of which the offices open. 
loOq 




I'ig- 335- — l^r- John B. Murphy's private office. 




^'•g' 336. — Stairway leading to the library. 




i' i^'- 23^- — Library and lounging room. 
1067 




Fig. 339. — ^Waiting room for Dr. Murj)li\ 's patients. 




I'ig. 340.— <JlUtc of Dr. Murphy's .scircLa.r>'. 
10O8 




Fig. 341. — Ladies' writing room. 




Fig. 342.— Dr. Philip H. Kreuscher's office. 
1069 




Fig. 343, — Dr. Gcori^c W . Iloclirciu's uliicc. 




I'lK- 344- KxuminiiiK and dressing r(M)ni. 
1070 




Fig. 345. — Another waiting and resting room. 




Fig. 346. — X-Ray room. 
1071 





H 


1 

y 






1 



Fig. 347. — Photographic studio where cases are photographed. 




I 1;^ vj"^- I'iliiiv: room for ihc .v-ray plates. 
1072 




Fig. 349. — Laboratory. Room No. i. 




Fig. 350. — Laboratory. Room No. 2. 
1073 



■^ 


^ 


^^C" 


1 ' 


^^B ^^^ 


k. 


^P w 


A 


"^^^Q^ 


^ 




m > 


WKj^^mm-'^iiiWi?- 


7 m^-^. 



Dr. Charles L. Mix 




I'ig. J51. I)r. (Iiarlrs L. Mix's ollkc. 
1074 




Dr. Richard J, Tivnen 
Head of Eye, Ear, Nose, and Throat Department 



I 




mssM 



Fig- 352. — Dr. Richard J. Tivnen's private office and examining room. 

1075 




Kig. 353, — Wailing room for pat iciiis 01 1 ^rs. ku liard J. Tivnen and Charles L. Mix. 



1076 



MURPHY'S CLINICAL TALKS ON SURGICAL 
AND GENERAL DIAGNOSIS 

FRACTURE-DISLOCATION OF THE SPINE AT THE 
LEVEL OF THE TWELFTH DORSAL VERTEBRA.— 
PRESSURE OF THE LOWER FRAGMENT ON THE 
SPINAL CORD.— SYMPTOMS. — DIAGNOSIS.— LAMI- 
NECTOMY.— NEUROLOGIC PHASE BY DR. CHARLES 
L. MIX 

HISTORY 

The patient, a man aged fifty-five, entered the hospital April 
2, 19 14. His family history is negative as to tuberculosis and 
cancer. His wife has had one miscarriage. Nine children have 
been born to him since this miscarriage, all of them healthy. 
He had the usual diseases of childhood; t3^hoid at twenty-two, 
imcomplicated, and measles at thirty-five. He denies all ven- 
ereal infection. 

The patient was perfectly well until four years ago, when, in 
August, 1909, while walking along the road, he accidentally 
stepped into a hole about 14 inches deep with his left foot; at 
the same time he fell on his right knee. He felt no bruises from 
this accident, and worked without inconvenience all day. That 
night, however, he noticed a slight, stinging pain just above the 
left hip, which continued until about five days later. These 
stinging pains, which were darting in character, passed into the 
left groin and across the lower abdomen from left to right, and 
also seemed to go from the left hip to the small of his back, but 
did not radiate down into his thigh at any time. His condition 
remained the same, and he noticed no additional symptoms until 
May, 19 10, nine months later, when, in walking, the toes of his 
left foot seemed to wobble and become uncontrollable. About 
one week later the whole anterior part of the foot became numb. 

1077 



IcyS CLINICS OF JOHN B. MUKPHY 

This condition continued until about the last of June or the first 
of July, 1910, when, while walking with the aid of a cane one day, 
the left limb suddenly gave way under him and he fell to the 
ground. He does not recall whether sensation was present in the 
limb at this time, but he does remember that the stinging, dart- 
ing pains in his left groin stopped after this accident. He con- 
tinued to walk about on crutches for a period of three weeks, 
when, one morning, on attempting to get up, he found that the 
right leg was paralyzed. Two days later he had trouble in start- 
ing the flow of urine and used a hot- water bottle to assist him. 
It severely burned the inner side of his thigh, but caused him 
little, if any, pain. This was the first time that he noticed loss 
of sensation in the thighs. In August, 19 10, he had an attack of 
chills and fever, the chills lasting fifteen minutes and appearing 
every two days. The doctor pronounced it malaria. He could 
control the passage of urine and feces imtil May, 191 1. Since 
then he has had in voluntaries. In May, 191 1, he went to a 
sanatorium and the doctor there noticed a swelling in the median 
line of the back, just above the first sacral vertebra, about the 
size of a dollar. This swelling, he says, was soft, and became as 
sore as a boil, but did not break open. Every time it was touched 
it would cause terrific pains to shoot down the patient's thighs and 
also into the abdomen. This swelling lasted until October, 191 1, 
when it gradually disappeared; but the pain in the sacral region 
of the spine has remained. So far as he knows, he had no chills 
or fever at any time while the swelling was present on the back. 

About one year after both limbs became paralyzed he suffered 
with scalding sensations on the outer surfaces of both thighs from 
the hips to the knees, which still occasionally occur. He has no 
sensation below the groins or about the rectum and genitalia. 

Paralysis of both legs is spastic, and the legs often jerk. The 
muscles are not distinctly atrophied, but the left thigh and leg 
seem slightly smaller than the right. All the reflexes are exagger- 
ated. Ankle-clonus is present on both sides. He has a double 
Babinski. Protopathic sensation extends from the level of 
Poupart^s ligament and the groin upward to a point just below 
the umbilicus, where cpicritical sensation is present. All tactile. 



CLINICAL TALKS ON DIAGNOSIS IO79 

heat, and cold sense is absent below this level. The deep tendon 
sense in the legs is present, at least to some degree. 

COMMENTS AND OPERATION 

Dr. Murphy (April 6, 19 14): The previous history of this 
patient appears to have no bearing on his present trouble, which 
began with the accident in August, 1909, practically five years 
ago. He stepped into a hole with his left leg and fell on his right 
knee. Then he had pain in his back, leading down into the groin 
region and down into his left thigh. This pain lasted only for a 
short time, and then entirely disappeared. In the following 
year, 19 10, the patient noticed the pain returning. He noticed 
at this time that his toes began to wobble and he began to lose 
control of them. Then, one day, his left leg went out from under 
him and he fell to the ground. What nerve is involved when the 
knee gives way, if it is a nerve lesion which is at fault? 

Intern: The anterior crural. 

Dr. Murphy: That is correct. The patient noticed a loss of 
sensation on the external and anterior portions of the left thigh. 
In May, 191 1, he developed in his back a painful, bulging area. 
This area became extremely sensitive to the touch. The patient 
describes it as swollen. Pressure on it produced radiating pains 
into the thighs and lower abdomen. This swelling finally dis- 
appeared. Preceding this soreness in his back he had an attack 
of chills and fever. Now, chills and fever in connection with 
injuries to the spinal cord and spine are rather suggestive of the 
development of a cystitis. But did he have a cystitis? I think 
he did not. Why? Because he had not been catheterized. ^ He 
had no urinary trouble at all until after his chills developed. The 
patient's x-ray plates were negative. 

I will ask Dr. Mix to take up the case from here and give you 
his findings from a neurologic standpoint. 

Dr. Mix: The history shows that the patient was injured by 
stepping into a hole when he walked around his house after dark 
in August, 1909. His house was being elevated and the workmen 
had dug a hole at one comer in order to put in a jack to raise the 
house. The patient did not know about the hole when he walked 



Io8o CLOnCS OF JOHN B. MURPHY 

around the house in the dark, and he stepped into it. He stepped 
into the hole with his left leg. The hole was two feet deep. He 
immediately felt a severe pain in his left hip. This pain ran 
around the groin and down, in the direction of supply of the ilio- 
inguinal and iliohypogastric nerves. In describing the location 
of the pain he traced with his hand the exact course of these two 
nerves, which come from the first segment of the lumbar cord. 
This fact at once presents us with a point of localization of con- 
siderable importance. One feels instinctively that the location 
of the pain at the time that he stepped into the hole marks the 
site of the lesion. 

This pain lasted, with more or less severity, three months 
before he saw a physician. He thought he had merely wrenched 
his hip, but at the end of the three months he decided that the 
pain should have gone away, and since it was still present, he 
thought he ought to see a physician. The physician was imable 
to discover the cause of the pain, though he thought that it was 
rheumatism. The patient himself, however, was of the opinion 
that it was due to his injury. 

He went along for a period of some months bearing his pain, 
until finally, in Jime, 1910, he began to be weak in his left leg. 
Within a period of two weeks' time the weakness in his left leg 
became so great that it was almost a paresis. Then suddenly, 
over night, the right leg became as weak as the left — all in a 
period of twelve hours' time. From that time on the patient 
was paraplegic. 

Following this paraplegia there is a history of chills and fever, 
which have been spoken of, which were attributed by his physi- 
cian to malaria, which the patient himself believes were due to 
malaria, and which we also can find no cause for other than ma- 
laria. 

Following the chills and fever there was a period of about a 
year in which there was a gradual development of sensory symp- 
toms. At first these were quite slight, but gradually they be- 
came more severe, creeping up the thighs to the level of the origi- 
nal pain, which was as high as the upper part of his hip following 
the crest of the. ilium and the groin. 



CLINICAL TALKS ON DIAGNOSIS I081 

Physical /examination was first directed toward his reflexes, 
especially his ankle- and knee-jerks. They were found increased. 
Ankle-clonus could not be obtained at the time of my examina- 
tion, but there was a most excellent history of clonus. Ankle- 
clonus commonly means what? A lesion in the spinal cord and 
not in the cauda equina. In the cauda equina only the lower 
motor neurons are to be found. In the spinal cord, in the pyram- 
idal tracts, upper motor neurons are to be found, and clonus 
always means an involvement of upper motor neurons. The 
presence, therefore, of ankle-clonus marks the case as a spinal 
cord case rather than a cauda equina case. Furthermore, when 
you examine his plantar reflexes, you find that he has a double 
Babinski reflex, again pointing unquestionably to an injury of 
the crossed and direct pyramidal tracts. Furthermore, there is a 
history of bladder disturbances which came on about the time of 
the paresis in the legs, at a time when we would expect them to 
appear. Such an involvement of the bladder means a level at 
least as high as the second lumbar segment of the cord. 

For two reasons we know we are dealing with a spinal cord 
disturbance: First, there is a double Babinski reflex with ankle- 
clonus, meaning an involvement of the pyramidal tracts. Sec- 
ondly, there is an involvement of the bladder. This always 
means a spinal cord disturbance, provided that there is no in- 
volvement of the fourth sacral nerve which gives off vesical fila- 
ments to the sphincter of the bladder. There was also rectal 
disturbance. With the onset of the sensory symptoms there 
was marked anesthesia of the rectum. He has no more knowl- 
edge concerning his bowel movements than he has concerning 
his urinary escape. 

There is another very important factor in his case, that is, 
the history of adductor spasms and, sometimes, a spasm of the 
gluteal group. This means an irritation of the pyramidal tracts 
of the cord. These irritated upper motor neurons then transmit 
their irritation impulses to the anterior horn cells, which transmit 
them to the muscles, thus giving rise to the spasms. When the 
pyramidal tracts are in a state of continued irritation, the spasms 



I082 CLINICS OF JOHN B. MURPHY 

occurring in the lower motor neuron territory in the gluteal and 
adductor groups constitute proof of this irritation. 

Where is the lesion? We must decide that point first if we 
are going to operate on him at all. You cannot tell by the mus- 
cular involvement in his case, because his muscular pareses are 
such that although he can move his legs a little, yet one cannot 
tell where his muscle power is intact and the level at which muscle 
power becomes involved. You can, however, make a sharp line 
of demarcation by means of the sensory disturbances. He has 
two levels of sensation, the first being lyi inches below the level 
where sensation becomes abnormal. This level marks the level 
of anesthesia. The upper level, i^ inches above the lower, 
marks the point at which sensation passes from natural to un- 
natural; it is at the level of the ilio-inguinal and iliohypogastric 
nerve supplies. This stamps the localization. Below the ilio- 
inguinal and iliohypogastric territories, supplied by the first 
lumbar segment of the spinal cord, sensation is present, but it is 
not natural. What would this lead one to infer? It would lead 
one to infer that the patient's trouble is situated at the level of 
the twelfth dorsal vertebra, which is located at the level of the 
first lumbar segment of the cord. 

This conclusion leads one to believe that something must have 
happened to the spine at the time of his original injury. What 
did happen? It is a difficult thing to work out. If a tumor 
followed the injury, the tumor must be one which has an exceed- 
ingly slow growth, hardly belonging to the sarcoma group. Since 
the pain followed the accident immediately, that is, a sensation 
of pain instantly at the level of the ilio-inguinal and iliohypo- 
gastric territory of supply, it is perfectly obvious to me that he 
had some kind of a fracture-dislocation of the twelfth dorsal 
vertebra. Whether there has subsequently formed some in- 
flammatory mass which has led to further compression or not 
we cannot tell. It is, therefore, necessary in the case of this 
patient to do an exploratory decompression. 

Since we do not know exactly what etiologic factor is present 
at this level, unless it be traumatic, it will be necessary to open 
up and free the spinal cord from whatever pressure is being ex- 



CLINICAL TALKS ON DIAGNOSIS I083 

erted upon it. I believe the disturbance was originally a left- 
sided one, starting from the left and spreading to the right, and 
I cannot account for the sudden involvement of the right leg 
over night, except on the basis of some secondary vascular dis- 
turbance. It often happens, however, in lesions of the nervous 
system that irritations do not produce any effect until they reach 
a certain degree, and the law of summation of stimuli is frequently 
exemplified in cerebral and spinal trnnors. Although the tumor 
may have been growing for a long period of time, the symptoms 
may suddenly appear. It is likely, therefore, that the explana- 
tion for the sudden appearance of the paresis of the right leg may 
be either vascular or based upon some such law as that of the 
summation of stimuli. 

Trophic disturbances were present in this man's case. He 
has had trophic disturbances in his left leg, showing involvement 
of some of the gray matter of his spinal cord. Ordinarily such 
trophic disturbances take place when the gray matter of the cord 
is involved, at or near the central canal of the cord. We must 
assume, therefore, in his case that there is some involvement of 
the gray matter on the left side of the spinal cord, and not much, 
if any, upon the right. 

Briefly recapitulating: this patient doubtless had a fracture- 
dislocation of his twelfth dorsal vertebra at the time that he 
stepped into the hole. Following this, possibly due to the grad- 
ual development of some inflammatory products, there was the 
gradual development first of the motor symptoms upon the left 
side, then upon the right side, and finally of sensory disturb- 
ances. The spinal cord evidently was involved first on the left 
side in front and subsequently on both sides in front and then 
posteriorly, because of the ultimate development of sensory 
symptoms. 

The level at which this lesion is to be found is indicated by the 
level of the original pain and by the level of the disturbance of his 
epicritical faculty. This level was found to be in the ilio-inguinal 
and iliohypogastric territory supplied by the first lumbar segment 
of the cord which underlies the twelfth dorsal vertebra. An ex- 
ploratory laminectomy must, therefore, be done at this level. 



1084 CLINICS OF JOHN B. MURPHY 

[While Dr. Mix was talking, Dr. Murphy proceeded with the 
laminectomy, in which he followed his usual technic, which has 
been described in previous numbers of the Clinics.] 

Dr. Murphy : There is practically no deviation in the spinous 
processes — ^just a little sinking-in of them. The point at which we 
intend to make decompression is between the eleventh and twelfth. 
[The usual muscular hemorrhage occurs.] These cases always bleed 
and bleed very profusely. We pack these gauze sponges into 
the wound for some time until the bleeding stops. I am separating 
these spinous processes so as to get them free. This patient is a 
very heavy man and his bones and ligaments are correspondingly 
strong. 

Let the record show that a spicule of bone from the fractured 
vertebra was compressing the cord against the wall of the twelfth 
dorsal vertebra; that it evidently compressed the cord more on 
the left than on the right side, because of the great deviation of 
the cord to the right; and that the spiculum of bone was removed. 
I presume that it was the continual irritation of that piece of bone 
as well as the pressure produced by it which led to the patient^s 
trouble. 

Let the record show that we removed the spinous processes 
and laminae of the eleventh and twelfth dorsal vertebrae and first 
lumbar; that the twelfth dorsal vertebra pressed into the cord on 
its left side so severely that when the bone fragment was re- 
moved the depression in the cord remained; that the dura was 
not opened; that we inverted muscle-flaps into the dead space be- 
tween the ends of the spinous processes and between the trans- 
verse processes and the laminae; that the bleeding from the bone 
was much less than in the average case; that the displacement 
in the spine was easily exposed and was found to be an antero- 
dextrolateral displacement of the lower fragment. 

[Note. — The operation wound healed by complete primary 
union. The patient's recovery from the operation was rapid and 
uneventful, with the exception that the bed-sore over one hip, 
with which the patient entered the hospital, led to a suppuration in 
his trochanteric bursa, prolonging convalescence, but ultimately 
healing completely. The patient left the hospital on June 6, 19 14, 



CLINICAL TALKS ON DIAGNOSIS I085 

two months after the operation. The control of his sphincters 
was very satisfactory, but the condition of his limbs had not im- 
proved sufficiently to permit him to go about without the assistance 
of crutches. — Ed]. 



APPENDICITIS IN PREGNANCY.— APPENDECTOMY 



fflSTORY 

The patient is a married woman, aged twenty-four years. 
Her present trouble dates back to one year ago (1910), when she 
had pain over McBurney's point, with no fever, nausea, vomiting, 
or rigidity. The pain was very acute and lasted for eighteen 
hours. Thereafter she felt all right xmtil June, 19 14, when she 
had another attack of pain in the same location, accompanied 
by local tenderness and vomiting. Her temperature, taken two 
hours after the onset of the pain, was 102° F. She was in bed for 
two days. The pain then gradually began to diminish, but the 
soreness remained. She had a third attack of pain about three 
weeks ago (August, 19 14), which was not just hke the previous 
attacks, the pain being somewhat lower in the abdomen than 
previously, but always on the right side. 

Menstruation began at the age of twelve, is usually of five 
days' duration, and averages four napkins a day. Her last period 
was July 25, 1914. 

COMMENTS AND OPERATION 

Dr. Murphy (September 14, 1914): This is the most im- 
portant of all the cases on the list today. It is the most impor- 
tant both from a teaching and from a clinical standpoint. Hers 
is a very interesting and instructive history. What^ is her tem- 
perature now? 

Intern: Her temperature this morning was 99.4° F. Last 
night it was 98.8° F. 

Dr. Murphy: What is the matter with her? 

Intern: She has an infection of the appendix — a chronic 
appendicitis. 



I086 CLINICS OF JOHN B. MURPHY 

Dr. Murphy: Yes, and what is the matter with her? 

Intern: She has not menstruated since last July and is 
probably pregnant. 

Dr. Murphy: Yes! That is what is the matter with her. 
That is the serious part of this situation. She has a history of 
recurrent attacks of appendicitis and a history of one mild mani- 
festation since she became pregnant. Pregnancy in appendicitis 
is one of the most dangerous conditions that occurs in the lower 
abdomen. With appendicitis in pregnancy there is a colossal 
mortality percentage when one does not operate, and an only 
slightly lower percentage when one does operate, except in the 
cases which are operated within the first few hours of the attack, 
before the disease has become a constitutional infection; that is, 
before the pus has been absorbed into the circulation and the 
microorganisms are circulating in the blood. 

If a local abscess forms, the danger of a general peritonitis 
developing from it is very great. In a patient in the third or 
fourth month of pregnancy the intestines and omentum have 
been pushed by the growing uterus out of the field where they pro- 
tect the caput coli, and so cannot encapsulate and care for the 
inflamed appendix. Consequently, there is a marked tendency 
to the development of a fulminant peritonitis. 

An equally serious condition, however, consists in the presence 
of microorganisms floating in the patient *s blood, into which 
they have escaped from the appendix. In the ordinary case 
of acute appendicitis this low grade of septicemia is of relatively 
slight importance. In acute appendicitis comphcating preg- 
nancy, however, abortion or miscarriage is very liable to occur, 
and, when it does, the presence of pyogenic microorganisms in the 
blood assumes an overwhelming importance. An infection at 
the site of the placental attachment in the uterus develops, and a 
fatal termination is the usual consequence. That is why we 
have advised this woman at this time, in the interim between the 
attacks, to have her appendix removed. 

There are possibilities of error in diagnosis in these cases. 
The first possible source of error is a tubal tuberculosis. In the 
latter alTt-ction ;in iilniost cxactlv similar attack of acute abdom- 



CLINICAL TALKS ON DLA.GNOSIS I087 

inal pain and vomiting, with fever, occurs as in an acute appen- 
dicitis attack. There is also an accompanying enlargement of 
the uterus, the result of tuberculosis of the endometriiun, more 
or less induration in both fornices, and a history of suspension 
of menstruation. But in tuberculosis the Abderhalden test for 
pregnancy is negative. Therefore in this case we were not 
satisfied that the patient's menstruation was suspended because 
of pregnancy until we had an Abderhalden test made. Her 
serum gave a four plus (+ + + +) Abderhalden reaction; that 
is, the test was superlatively positive. Consequently, we were 
quite certain that the patient was pregnant and that she had not 
a tubal tuberculosis, but an acute appendicitis complicating 
pregnancy. In connection with the Abderhalden test we have 
had two or three very interesting cases which I shall speak of in 
a moment. Before going into that matter — I am waiting until 
the patient is fully under the influence of the anesthetic before 
making the incision, because we want the reflexes reduced to a 
minimum, in order to diminish to the limit the likelihood of 
abortion — I will say that miscarriage in the pregnant is very 
common after operations for appendicitis. If the appendix be 
removed in a practically clean condition, that is, when the in- 
flammation is of mild degree and is confined entirely to the inside 
of the appendix, then there is practically no danger of infection 
of the uterus occurring by way of the blood-stream, even if 
abortion ensues. That is what we hope to accomplish in this 
case. With the acute attack already three weeks past, we hope 
to find the appendix back practically to normal at the present 
time. That is why we are doing the operation now — to elimi- 
nate the great danger of subsequent acute attacks during the 
course of this pregnancy. 

I have asked Dr. Sweek to talk on the diagnostic value and 
the technic of the Abderhalden test while I am carrying out the 
operative steps. Dr. Sweek is our pathologist. 

Dr. Sweek: When foreign proteins of any kind find their 
way into the blood-stream, they are not in condition to be used as 
food by the body-cells. They must first undergo parenteral diges- 
tion. This is brought about by some substance produced by the 
VOL. ni — 68 



I088 CLINICS OF JOHN B. MURPHY 

body-cells or by chemical changes in the blood-stream. After a 
foreign protein has imdergone this process of parenteral digestion, 
it is in a condition to be used as a food for the body-cells. 

We know that in enteral digestion the protein molecule yields 
active poisons among them the proteoses; but in normal digestion 
these substances are split into harmless bodies before absorption into 
the circulating media of the body. In parenteral digestion such 
poison is set free, and if in sufficient quantity, gives rise to dis- 
turbances with clinical manifestations somewhat resembling an 
infectious disease. The symptoms produced by injecting casein 
into a human being are very similar to those produced by an acute 
infection, except that they disappear spontaneously if no more 
protein is injected. 

If we inject protein substances in minute quantities continually 
or at intervals, no untoward symptoms or discomfort of any kind 
is produced. [Of course guinea-pigs, which are easily sensitized, 
would show a marked anaphylactic reaction, but man, who is 
not easily sensitized, would usually develop an immunity. — Ed.] 
It has further been shown that increasing doses of protein may 
be given at intervals without increasing the severity of the 
symptoms produced or even without producing any symptoms 
at all after the first dose. If, however, we change the protein 
used, as, for instance, from casein to egg-albumen, serum-albumin, 
or bacterial albumin, the toxic symptoms will again manifest 
themselves, showing that the production of tolerance for one 
variety of protein does not establish a similar tolerance for other 
varieties. This tends to show that the immunity obtained is 
specific for each individual protein. Many facts are now at hand 
to prove that the parenteral digestion of a protein substance is 
increased by increasing the amoimt of protein injected into the 
circulation. The high degree of specificity of this immunity re- 
action b well shown in the production of anti-sheep's-corpuscles- 
amboceptor in the hemolytic system so commonly used in the 
Wassermann test. 

Schmol, Veit, and Seichardt demonstrated that chorionic 
epithelium enters the circulation during pregnancy. H. Peters, 
Herzog, H. Strahl, R. Rcineke, J. H. Price, and J. H. Teacher 



CLINICAL TALKS ON DLA.GNOSIS I089 

found that chorionic villi are present in the fertilized ovum within 
the first month after fertilization. With these facts and the 
knowledge that proteins native to the species may act like foreign 
proteins when injected into the blood-stream and cause the mobili- 
zation of specific ferments in the blood capable of reducing or 
digesting these proteins, Abderhalden had the working basis 
on which to develop his serodiagnosis of pregnancy. He states 
that these antichorionic ferments appear in the mother's blood 
in demonstrable amount as early as six weeks from the first day 
of the last menstruation, and continue present there for fifteen 
days after the termination of pregnancy. 

The materials necessary for performing the Abderhalden test 
for the presence of enzymes capable of digesting placental tissue 
are: Dialyzers, Seilecher and Schuell, 579 A; glass containers, either 
large, wide-mouth test-tubes or two-ounce bottles; glassware; 
prepared placental albumin, and ninhydrin solution. 

Technic of the Test. — The Preparation of Placental Albu- 
min, — This albumin must be white in color and free from all dialyz- 
able proteins at the end of the procedure of preparation. It is 
prepared in the following way: Over a 5000 c.c. porcelain bowl 
stretch two thicknesses of sterile canvas; slit the canvas up five 
inches, so that each layer is cut and the cuts cross, thus leaving an 
opening through which the placenta may be dropped immediately 
that it has been expelled by the mother. The slits in the canvas 
close immediately after the placenta has passed them. Com- 
plete asepsis must be practised in this manoeuver. This bowl 
should be filled with physiologic saline and taken to the labora- 
tory at once. There it should be torn into small bits, the size 
of a navy bean, sterile gloves being on the hands of the operator 
and a constant flow of physiologic saline continually passing 
through the bowl. This can best be accomplished by setting the 
bowl in the sink and allowing the saline solution to flow in from a 
large demijohn through a piece of sterile rubber tubing. At the 
end of an hour most of the blood will have been washed out and 
the placenta will be nearly or quite white. Of sterile water, five 
times the volume of the placenta should be added. Then add 
one-half cubic centimeter of glacial acetic acid. Boil five minutes. 



logo CLINICS OF JOHN B. MURPHY 

Pour off the supernatant fluid and repeat this process twice. 
Then test the tissue with the biuret and ninhydrin reactions. 
This should be done in the following manner: Take a small 
piece of the white placental tissue in sterile forceps and place it in 
a test-tube containing 5 c.c. of water. Let this test-tube stand 
at room temperature for two hours. Then apply the test. If a 
bluish color is obtained with either test, the placental tissue should 
be subjected again to boiling, repeating the process imtil a negative 
reaction is obtained. If the test is still positive after the sixth 
boiling, the placenta should be discarded altogether and another 
placenta similarly prepared. 

TJie Serum to he Tested. — Not less than 10 c.c. of blood should 
be drawn from the patient's arm directly into a sterile centrifuge 
tube, which is then closed with a rubber stopper. This tube 
should be allowed to stand at room temperature until the blood 
is clotted. It should then be placed in the ice-box for two hours, 
then centrifuged, and the serum pipeted off for use. The dialyzers 
should all be tested before using. Place the dialyzers for twenty- 
four hours in sterile distilled water underlaid with one-half inch 
of chloroform. Cover the top of the water with two inches of 
toluol. The glass container for carrying out this procedure 
must be properly sterilized. After twenty-four hours remove the 
dialyzers, drop them into boiling water for one minute, then re- 
place them in a hermetically sealed glass jar in fresh sterile dis- 
tilled water underlaid with chloroform and overlaid with toluol as 
before. Repeat this process on three successive days. Then let 
the dialyzers remain in the water for five days, changing the 
water, chloroform, and toluol daily. After this period has elapsed 
they should be again boiled for one minute and they are now 
ready for testing. First test their permeability to peptone. Use 
a 2 per cent, solution of Seiden-pepton. If they are found to be 
either too impermeable, or too easily permeable to peptones, they 
should be discarded. Next test their permeability to serum- 
albumin, discarding those which allow albumin to pass through. 

Setting up the Test. — ^Large test-tubes, of sufficient diameter 
to allow a one-half centimeter interval between the glass and the 
dialyzing shell, or small, wide-mouth boUk'S, are used. Place in 



CLINICAL TALKS ON DIAGNOSIS IO91 

each bottle or test-tube 20 c.c. of sterile [distilled water. Place 
1% grams of prepared placental albumin covered with 1.5 c.c. of 
serum in a tested dialyzer. Place this dialyzer in the bottle, cover 
both senmi and water with toluol, and set the bottle and contents 
in the incubator at 37.5° C. for sixteen hours. Then test the 
water surrounding the dialyzer for the products of placental di- 
gestion. This is done as follows: 

Ten c.c. of the dialysate is put in a clean sterile test-tube and 
heated over an even flame, or, preferably, in a brine bath, untU 
the first bubble of steam appears. Then add 2 minims of a i 
per cent, ninhydrin solution. Boil one minute. If the placental 
tissue has undergone digestion, a distinct amethyst color is ob- 
tained. Each test should be done in duplicate with a suitable 
control. The control should consist of the patient's serum, in- 
activated by heating for thirty minutes at 57° C, and placental 
albumin, the quantities being the same as in the test itself. 

In carrying out 32 of these tests E. K. Langford and I each 
made the tests independently, both using the same technic. We 
obtained the same results in 29 cases. 

JeUinghaus and Loose report 4 per cent, of error in tests on 
known pregnant women, and 8 per cent, of error with known non- 
pregnant serums. CM. Echols, of Milwaukee, reports that from 
10 to 12 per cent, of non-pregnant serums give positive reactions. 
F. H. Falls, of Chicago, reports 12 per cent, of positive reactions 
in non-pregnant cases. In our own report we have left out the 
early cases, because our failures were numerous and were, to a 
large extent, due to errors in technic. Our last 78 cases, done when 
our technic was improved and our results fairly uniform, are as 
follows: Of the 78 cases, 42 were known pregnant serums and 
36 were known non-pregnant serums. In the 42 known pregnant 
cases we had 3 failures; in the non-pregnant, 4 failures. Of the 
36 non-pregnant cases, 4 were carcinoma, 11 appendicitis, i gall- 
bladder disease, 3 arthritis. The remainder were apparently 
normal individuals. One normal individual gave a positive test. 
One arthritis gave a positive test. Two appendicitis cases gave a 
positive test. 

The work of JeUinghaus and Loose, and of Schwartz, of St. 



1092 CLINICS OF JOHN B. MURPHY 

Louis, has been of great value to me in helping me to eliminate 
many of my earlier mistakes. This test must be regarded as still 
in the experimental stage. A negative reaction as yet is of con- 
siderably more value than a positive reaction. On the whole, 
we cannot say that the test is valueless and should be discarded 
because it is occasionally in error. Neither is the Widal test in- 
fallible nor the Wassermann test. It should be carefully performed 
with strict adherence to Abderhalden's technic, and the results 
coupled with other clinical and laboratory data. It should be 
used as an aid to diagnosis and not as a positive and final diagnosis 
by itself. 

Dr. Murphy: Let the record show that the patient's uterus is 
enlarged to the size of a six or eight weeks' pregnancy; that the 
tubes and ovaries are free from both adhesions and indurations; 
that there is a slight amoimt of serous fluid in the peritoneal 
cavity; that the appendix has, apparently, fully recovered from 
the last attack; that the tip of the appendix was free from adhe- 
sions, as we should expect it to be after this mild type of attack; 
that is, she has never had an attack severe enough to produce 
a peritoneal effusion, with consequent adhesion formation; in 
other words, that the clinical findings corresponded closely with 
the pathologic findings. 

What was the leukocyte count in the cases that gave a positive 
Abderhalden reaction? 

Dr. Sweek: There was no leukocytosis in 32 of them. In 
8 of them we had only a red-cell count made. 

Dr. Murphy: The presence of leukocytosis in pregnancy 
is an indication to the doctor to look out for complications. Dr. 
Sweek, I should say, is rather pessimistic in the stand he takes 
as to the value of the Abderhalden test. I interpret this test merely 
as an aid to the other signs and symptoms in the individual case. 
I give it a relative, but not an absolute, value. No laboratory 
test attains the 100 per cent, correctness of perfection. The 
laboratory method, as well as the clinical method, has its errors. 
Many laboratory men, in the years gone by, have upheld the 
practical infallibility of their methods with a cocksureness which 
the facts do not and did not justify. I think that the laboratory 



CLINICAL TALKS ON DLA.GNOSIS IO93 

men have grown away from that early cocksureness and are now 
incUned to err in the opposite direction. They have fomid their 
method in error so frequently that they are becoming a little too 
conservative and timid. We have fomid the Abderhalden test 
of decided value. 

The gist of what Dr. Sweek wishes to impress on you is that 
certain cells, known as the sjoicytial cells of the decidua, throw 
into the blood protein products of their metaboHsm. An enzyme 
proteolytic to that particular cell protein is produced somewhere 
in the body by the tissue-cells and is present in the blood-serum 
of the pregnant woman. Abderhalden's reaction is a test for the 
presence of that enzyme in the blood-serum. That is the essential 
nature of the reaction. Though the principle of the method is 
simple, the technic of the reaction is so very delicate, and the 
possibilities of error so numerous, that much of the value of the 
reaction is lost because of the practical difficulties in making cer- 
tain that all sources of fallacy have been eliminated from the 
test. 

One needs the test in connection with certain cases of uterine 
fibroids, where the co-existence of pregnancy is suspected, and, 
as in this case, in connection with an acute appendicitis accom- 
panied by amenorrhea and an enlarged uterus. You will find the 
details of the Abderhalden test given in one of the recent numbers 
of the Clinics (April, 19 14, p. 206). We used it there in connec- 
tion with a lesion in the pelvis, where it was of great differential 
value in the diagnosis. The patient had been married twenty- 
two years and had never been pregnant. She came to the office 
on account of some gastric disturbance. She then had not men- 
struated for something like five weeks. She had no other signs 
or symptoms except a sKght sensitiveness to the right of the 
uterus. It was perfectly proper to believe that she had so long 
failed to become pregnant because of some lesion in her tube, 
possibly, and that, having been married twenty-odd years with- 
out a pregnancy, her sterihty might be considered permanent. 
But there was something about the case, call it a " hunch, *' or call 
it what you will, which suggested to me that, no, this was a 
pregnancy, not an old tubal infection. The more I thought about 



I094 CLINICS OF JOHN B. MURPHY 

the case, and the more I elicited of the patient's history, the more 
I became inclined to believe that she had a tubal pregnancy. 
We sent her directly from the ofl&ce to the laboratory to have 
an Abderhalden test made. We received the report at 9 o'clock 
the following night that the reaction was positive. We telephoned 
the facts to the patient's father, who was a doctor, and had her 
removed immediately to the hospital, where the impregnated 
tube was removed the morning following admission. It was 
already ruptured and bleeding. The hemoglobin test made just 
before operation showed only 44 per cent, hemoglobin. One 
would not have suspected any such low percentage from her 
appearance; and without the Abderhalden test we might not have 
operated until the patient's hemoglobin had fallen to a highly 
dangerous degree. Her progress to recovery was iminterrupted. 

[Note. — This appendicitis patient made an imeventful re- 
covery, without either aborting or running a fever. She was 
shown in clinic about two weeks after the operation. — Ed.] 

Dr. Murphy (September 26, 1914): This is a patient with 
an acute appendicitis who had skipped one menstruation and 
was already two weeks over time on the next period. She had 
her first attack of appendicitis over a year ago. It was not very 
severe. When did you have the last attack? 

Patient: About two months ago. 

Dr. Murphy: Just after she became pregnant. The manage- 
ment of appendicitis in pregnancy is one of the most serious prop- 
ositions now existing in surgery, because the patient's life is 
enormously hazarded by the disease, and the surgeon's line of 
action increases or decreases that hazard very materially. I have 
put on the blackboard here an analysis of a series of these cases 
by Palmer Findley, and other series by other observers. The 
number of cases here recorded is relatively small to enable one 
to come to a definite conclusion concerning what should be done 
for these patients; but it tells us something, at least. 

In 1913 Palmer Findley reported 15 cases of appendicitis 
associated with pregnancy. Fourteen were operated — five were 
mild: all recovered. Ten were severe: seven recovered. There 
were three deaths. One fatal case was not operated. The attacks 



CLINICAL TALKS ON DIAGNOSIS IO95 

occurred: One in labor; five in the puerperium, and nine 
during pregnancy. 

Wagner estimates that the mortality in non-operative cases 
is 77 per cent.; while in cases operated within the first forty- 
eight hours it is 6.7 per cent. 

This mortality certainly can be reduced if the operation is 
performed within the first twenty-four hours of the attack. 

In the 15 cases that Findley collected there were 3 deaths. 
Think of that for a mortality in acute appendicitis ! In checking 
up the statistics on the other series of cases, however, I find that 
the mortahty in the non-operated cases was 77 per cent. Think 
of it! Three deaths out of every four when acute appendicitis 
comes on in pregnancy and does not have the benefit of operative 
intervention. When one comes to analyze the cases that are 
operated within the first forty-eight hours of the attack, — ^not 
the first twenty-four, but the first forty-eight, — the mortality 
sinks to 6.7 per cent.! That percentage is still too high — much 
too high — because it represents cases operated inside the first 
forty-eight hours instead of inside the first twenty-four hours of 
the attack, as they should be operated. 

What leads to this frightful mortahty in appendicitis in 
pregnancy? First, the non-operative cases. In the non-operative 
cases with the caput coli in the pelvis and the omentum and in- 
testines pushed up out of the field of trouble by the enlarged 
uterus, there is nothing to cofferdam or encapsulate the products 
of inflammation if they break through the appendix. The 
pus ruptures into the free peritoneal cavity. Then, added 
to that disaster, comes the infection of the blood and then the 
miscarriage. After the miscarriage the microorganisms get 
in the blood and are arrested at the point of placental attach- 
ment in the uterus. From the infected endometrium and 
myometrium the infection spreads into the uterine veins, a 
septic thrombophlebitis develops, possibly with pyemia, and 
then the patient dies. 

That is the cycle when these patients are not operated. 
What is the cycle when they are operated? It is practically the 
same as in the first, except that the peritonitis is avoided. When 



1096 CLINICS OF JOHN B. MURPHY 

the operation is performed very early, the septicemia is slight 
or absent. But when it is not carried out until forty-eight 
hours have elapsed, there are always some microorganisms 
already circulating in the blood. Then the patient aborts, 
and the hematogenous infection localizes at the site of the pla- 
cental attachment. 

What sliould be the management of such a case? Make the 
diagnosis, and make it early, as one always can, with the ex- 
ception, possibly, of the differentiation between an acute ap- 
pendiceal attack and a tubal pregnancy. If it is a tubal preg- 
nancy, it presents very little danger, so far as mortality is 
concerned, if operated before rupture and hemorrhage occur. 
The early operation for tubal pregnancy has not even the 
mortality that the operation for an ordinary appendiceal in- 
fection has. 

If one operates for appendicitis in pregnancy in the first 
six or eight hours of the attack, as one can in all these cases, 
when its importance is grasped by the physician and properly 
impressed on the patient, the mortality should be very slight. 
The urgency of these cases can scarcely be exaggerated when 
one knows that without an operative procedure the patient 
runs three chances of death to one of recovery. No other acute 
abdominal lesion, not even the ordinary suppurative peritonitis 
from perforation, has any such mortality. Peritonitis of ap- 
pendiceal origin unassociated with pregnancy has a mortality 
of about 4 per cent. It is the element of pregnancy, the fre- 
quency of septic abortion, which makes the difference in the 
mortality figures. 

It is because of the importance of this lesson that I brought 
in this patient today. She is a doctor's wife. In reading my 
article on this subject in the Year-book for Surgery, in which 
I brought out these same points, her husband said to him- 
self: *' My wife has had recurring attacks of appendicitis. She 
had one of them about the time she became pregnant. She 
may get another attack at any time, and so she had better be 
operated while the operation is relatively without danger.*' 
We accordingly took out the appendix in an interim operation, 



CLINICAL TALKS ON DIAGNOSIS IO97 

and she has not had an unpleasant symptom since. In per- 
forming an appendectomy in the presence of pregnancy one 
does the least possible manipulation of the tissues and viscera. 
Take out the appendix, close the abdomen, and go home. Do 
not handle the intestines. Do not endeavor to pull them up 
in the field. Pick up the appendix, tie, cut, and invert it, and 
get away. 

Remember that even a duodenal perforation does not begin 
to have the mortality that this condition does. If a doctor 
knew he had a case of duodenal perforation to deal with he 
would be in action on the firing line immediately. He would 
hurry his diagnosis and hasten his operation. When one sees 
an appendicitis in pregnancy the urgency of the case is even 
greater, if such be possible. Do not wait for such an appendix 
to "get ripe." Take it out! The sooner you get it out, the less 
Hkelihood there will be of the pyogenic microorganisms getting 
into the blood and leading to a fatal septic abortion. 



TALK ON APPENDICITIS— APROPOS OF A CASE OPER- 
ATED ON DURING THE PREVIOUS NIGHT 



Dr. Murphy (September 3, 1914) [Showing specimen]: 
This is a very pretty case and an instructive one. When we 
come right down to a heart to heart talk about appendicitis, 
the grim fact which we must admit is that we are still losing too 
many cases. We, the members of the profession, are respon- 
sible; there is no use in den3dng it. The facts concerning the 
symptomatology, course, and the results of treatment have 
been thoroughly established in many clinics on a multitude of 
patients. A physician today has no right to hold an opinion 
about appendicitis radically at variance with established prac- 
tice, based on a personal series of only 5, 10, 20, or even 100 
cases. So many able surgeons with well-organized clinics have 
handled and studied exhaustively thousands of cases that a 
man must be either a transcendent genius or an egotist who dares 



1098 CLINICS OF JOHN B. MURPHY 

oppose the present established views in terms other than those 
of numbers. 

Let me give you this patient's story: This man got on a 
train over in Iowa last Tuesday night, August 27th, about 10 
o'clock. About 12 o'clock he began to have pain in the abdomen. 
The pain continued very severe through the night. In the 
morning he took some kind of a powder, either salts or some- 
thing of the kind, to move his bowels. At 6 a. m. he vomited. 
When he reached Chicago he went to one of the smaller hotels. 
He called in the hotel doctor, who told him not to eat anything. 
That was that particular doctor's Hne of treatment, apparently, 
for an acute appendicitis during the first day of the attack! 
That is the "expectant plan"; you know what it means — ex- 
pecting something to occur; and it does occur with great fre- 
quency — perforation, abscess, general peritonitis, subdiaphrag- 
matic abscess, thrombosis, embolism, and the like. But the 
patient wanted to get well. So he sent for another doctor, 
who was no better, however, than the first, for he, too, put the 
patient on the ''expectant" treatment. Finally, a friend came 
to visit this victim of misguided judgment, and he was a real 
friend, for he insisted that something be done. Both doctors 
admitted that it was a case of appendicitis, — an early [case, — 
and yet they did not counsel operation. That is the part that 
is not clear. That is the point that is hard to understand. 
The patient had a temperature when he came to the hospital 
of 99.8° F. His pulse was not rapid and he had vomited only 
once. He was only slightly sensitive to pressure over his ap- 
pendix, but he had had severe abdominal pain all day. Any- 
body might say from that history that the man was probably 
getting well, for his pain, too, had practically subsided by night, 
and these few symptoms are about all one has to go by in most 
cases, anyhow. The doctor could say, "The appendix is drain- 
ing back through the cecum. The patient is getting along 
finely." 

I will show you how finely he was getting along. We made 
a leukocyte count upon his entrance to the hospital, and it 
showed 14,000 white cells to the cubic millimeter. That find- 




Gangrenous appendix referred to on page 1099. 



CLINICAL TALKS ON DIAGNOSIS IO99 

ing told the true story, in spite of the absence of temperature. 
We have had a few other cases like that. Here is his appendix. 
[Demonstrates it to the clinic. See colored drawing] You see 
that the whole appendix is completely gangrenous. It is about 
to perforate at that point (not far from the tip). Why did he 
have no fever? Because that appendix is dead and a dead 
appendix does not absorb either the toxic products of infec- 
tion, which are what produces the fever in inflammation, or 
anything else. That is why the temperature drops as gangrene 
sets in, and that is why the most dangerous cases are those in 
which the temperature drops and drops relatively suddenly, 
because those are the cases in which there is a complete gangrene 
of the appendix. The pain stops. Why? Because a dead 
appendix does not cause pain. Its nerves are dead and cannot 
transmit sensation. But just as soon as the Hne of demarcation 
forms and the contents of the appendix slip out through the 
slough into the peritoneal cavity, then the patient will have 
pain — and real pain — as the peritonitis develops. 

Let us go further. Why should one wait with that kind of a 
case? There is no reliable evidence at that time to show whether 
the appendicitis is going on toward recovery or to a fatal ter- 
mination. The temperature remains down, it is true. But 
why should you wait when you see a fire starting in a room 
full of combustible material until the temperature is so high 
that everything sizzles and bursts into flame? Why should 
you wait to call the fire engine until you see that the room is 
certainly going to burn up? That is the proposition in acute 
appendicitis. It is on that basis that we treat it and are always 
going to treat it. We took that appendix out, and it saved 
the patient's hfe because we did. It was lying free on the in- 
ternal iKac artery without the sKghtest adhesions around it. 
Why were there no adhesions? Because the appendix was 
dead, and dead tissues do not form adhesions to any structure. 
If it had died slowly, it would have had time to become encapsu- 
lated and care for itself; but it died so rapidly, en masse, that 
there was no time for adhesions to develop. We displaced the in- 
testines far away from the appendix with tampons. The mesen- 



IIOO CLINICS OF JOHN B. MURPHY 

teriolum of the appendix, which we had to divide, was very 
short, so that in taking out the appendix we had to do all our 
work within the peritoneal cavity. We could not reach the 
caput coli. Supposing we had waited until today and now had 
to take it out with all that gangrenous debris deep in the abdo- 
men, and we unable to bring the caput coli out of the abdomen. 
What would have happened? He probably would now be in 
inominent danger of death, that is all, instead of on the road 
to a rapid and uneventful recovery. See what it would mean 
today for that patient to have this appendix still within his 
abdomen. 

In my own family I had to face this identical condition just 
before I went away to Europe this summer. My youngest 
daughter came down to breakfast in the morning, about 7 
o'clock, after being out to a dance the night before, and said 
she had pain in her abdomen. She had not much local tender- 
ness, only slight temperature, — 99.5° F., — and had vomited 
twice during the night. I sent over to the hospital to have a 
leukocyte count made. She had 15,000 white cells in that count. 
Mrs. Mvuphy made the diagnosis, and she did it on this basis: 
My daughter had had several previous attacks of "stomach 
trouble," accompanied by nausea and emesis, followed by some 
soreness but no elevation of temperature. Mrs. Murphy said: 
"She had her pain first this time, then the nausea and vomiting, 
and now she has the elevation of temperatiure — 99.5° F.'* The 
symptoms were the same, but the order was reversed and the 
diagnosis different. I went over to the hospital and took her 
appendix out before completing my morning clinic. There 
was already a beginning gangrene of the mucosa of the ap- 
pendix. It would have been only a few hours before the entire 
appendix would have been gangrenous. So friable was it already 
that it ruptured while I was taking it out. But I had it out 
immediately, and thus forestalled all trouble. ''Now is the 
acceptable time for Salvation and for removing the appendix.'^ 
That is the way the matter of operative indications should 
be put, if I may be allowed to borrow thus the language of the 
second letter ,to the Corinthians. 



CLINICAL TALKS ON DIAGNOSIS IIOI 

There is another proposition that I feel I ought to talk 
about today, because Dr. Ochsner and I are in such full accord, 
so far as the management of the appendicitis case in the first 
forty-eight hours of the attack is concerned. The doctors who 
had this case before me believed they were giving the patient 
the Ochsner treatment. They were not giving him the Ochsner 
treatment at all. The Ochsner treatment for acute appendicitis 
is to remove the appendix early in the attack; but when the 
patient comes to you in the fourth day or in the last part of 
the third day of the attack with an acute appendicitis, that is 
the time, Ochsner beheves, that, unless you are a master of 
the situation, you had better let the appendix become en- 
capsulated and the abscess circumscribed, and handle it a little 
later as an abscess, by opening and draining it. That is the 
Ochsner treatment. During that period of walHng off, absence 
of all fluid by mouth and absolute rest in an elevated or Fowler 
position is the Ochsner treatment. Dr. Ochsner and I are 
absolutely in accord that all appendices should be taken out 
inside of the first forty-eight hours of the attack, if seen within 
that time, and if the diagnosis is made. For you must admit, 
if you are honest with yourself, that you cannot tell what the 
outcome is going to he in any individual case of acute appendicitis. 
You know, if you are anything of a surgeon, that you can take 
out the appendix with very much less danger to the patient 
in the early stage of the attack than at any other time. It is 
an entirely different proposition if you undertake to remove 
the acute appendix at the third day and after. Then you must 
be not only a master of the surgical technic of appendectomy, 
but also a master of the surgical principles governing the situa- 
tion. The most dangerous day on which to operate is the third 
or fourth, because on these two days one so frequently finds 
an abscess without local coffer-damming, inflammatory infiltra- 
tion and edema, without the additional development of a pro- 
tecting wall of leukocytes. All these factors have to be weighed 
in the balance when one undertakes to operate on the third or 
fourth day. If you open the abdomen and find an abscess, 
be happy to let out the pus, close the abdomen, and let the 



II02 CLINICS OF JOHN B. MURPHY 

appendix remain. Get out of that abdomen and do not think 
you have to make a complete operation. I well remember the 
meeting of the American Medical Association at Saratoga, 
when one of the surgeons told how he always made the complete 
operation in these cases, cleaning up everything, tearing up 
adhesions, and grubbing out the appendix. What happened? 
He had an i8 per cent, mortality in his report of these cases. 
And yet he was telling about it with pride! 

I will show you just where his idea of operating in that 
fashion came from. I will show you how we are led into error 
by not estimating, or by underestimating, a lot of important 
factors. In gynecology we were taught that when we find a 
pelvic pus-cavity, open the pus-cavity and take out the tube. 
But that pus is sterile. Schulze, away back in the early eighties, 
showed that in 8i per cent, of the cases the pus in pus-tubes 
is sterile. Twenty-five years later we learned that the reason 
why one can operate, in the presence of pus in the pelvis, with- 
out conjuring up disastrous events, when the pus has been there 
for months and years, is because the tissues are coffer-dammed 
and do not absorb more inflammatory products. But it is an 
entirely different proposition with the pus of an acute virulent 
appendicitis in an abdomen where there is no effort at coffer- 
damming or encapsulation. We know how difficult it is to 
infect a granulating wound, and how easy it is to infect a fresh 
woimd. It is just the same proposition exactly with peritoneal 
infection. One must think about each case and reason it out, 
pathology, causation, and treatment; but one must not try to 
group them. The individual bearings must be taken every 
time. 



CLINICAL TALKS ON DIAGNOSIS II03 

RECURRENT CHOLECYSTITIS.— CHOLECYSTOTOMY.— 
DIFFERENTIAL DIAGNOSIS OF CHOLECYSTITIS, AP- 
PENDICITIS, AND PYELITIS 



HISTORY 

The patient is a married woman, aged forty-four years. Her 
family and past personal history are negative. Menstruation 
began at thirteen years and was regular until about ten years 
ago. Then she flowed twice almost every month, three days at 
a time, until three years ago, since which time menstruation has 
ceased entirely. When she flowed only once a month the dura- 
tion of the flow was from six to eight days. 

Her present trouble began three years ago, when she began to 
have a feeling of distress in her stomach about two hours after 
meals, accompanied by eructations of gas. The distress was 
reUeved at times by taking a medicine which her doctor pre- 
scribed for her; at other times it was not influenced by the medi- 
cine. Sweets and coffee generally caused an aggravation of the 
distress. The attacks have been more severe in the faU of the 
year, as a rule. She has had no fever or jaundice, and has not 
been sufficiently incapacitated at any time to be confined to bed. 

In April, 1914, she was awakened one night with a very 
severe pain in the epigastrium, which radiated around into her 
back. The pain lasted from midnight until 7 o'clock the next 
morning. She had no chill, no vomiting, and no jaundice with 
the attack. She consulted no physician on account of it. She 
was all right the next day, and remained well for two months. 
Then she had another similar attack which lasted from four to 
six hours, also without jaundice. Since then, at irregular inter- 
vals, she has had a number of attacks of pain in the epigastrium, 
radiating to the right side of the abdomen, under the costal 
border. In the past two months she has had only two attacks, 
the last one two weeks ago. She feels quite well between the 
attacks. Her bowels tend to be somewhat constipated. The 
stools have never been clay-colored, so far as she knows. She 
has noticed no change in the color or quantity of her urine. 
VOL. m — 69 



II04 CLINICS OF JOHN B. MURPHY 

COMMENTS AND OPERATION 

Dr. Murphy: The history of recurrent attacks of distress in 
the epigastrium and right hypochondrium coming on more fre- 
quently in the fall and in the spring of the year is a statement 
often found in the history of a gastric or duodenal ulcer. The se- 
verity of the pain, together with its character, — not colicky, but 
intense and persistent, — is, on the other hand, a point which speaks 
strongly in favor of the diagnosis of a recurring infection in 
the gall-bladder. With such an infection we may or may not 
have gall-stones. We know that infections of the gall-bladder, 
particularly the infections of the recurring type, are very prone 
to lead to the formation of gall-stones. We know, on the other 
hand, that gall-bladders which contain stones are more prone 
to inflammatory attacks than normal gall-bladders. That the 
presence of gall-stones is necessary to the production of a chole- 
cystitis is an obviously absurd proposition, because it is only in a 
minority of acutely inflamed gall-bladders that stones are found. 
A safe statement to make is that in the great majority of cases 
infection of the gall-bladder is a more constant precursor of 
gall-stones than a successor. What part in the formation of 
gall-stones is played by the infectious microorganisms them- 
selves, and how much is due to obstruction of the cystic duct 
by inflammatory edema in its wall and by ropy mucus and 
inspissated bile in its lumen are matters for the pathologists to 
decide. In the near future we are going to devote quite a little 
more attention to gall-bladder infections, I think, than in the 
past, particularly in their relation to the production of secondary 
manifestations in the pancreas, probably chiefly by direct ex- 
tension of the infection along the mucosa of the ducts. But 
chronic infections of the gall-bladder as a factor in the production 
of metastatic infections in distant organs, especially the bones 
and joints, is a subject which is going to be much discussed and 
investigated, as well as the r61e of the gall-bladder in the trans- 
mission of diseases, such as typhoid and cholera, by ''carriers." 

The history of this patient contrasts markedly with the his- 
tory of the gall-stone patient operated on Wednesday. That 
patient gave a history of severe colicky pain, followed by nausea 



CLINICAL TALKS ON DIAGNOSIS II05 

and vomiting, associated on two occasions with chills, and fol- 
lowed on three occasions by jaundice and once by the passage 
of a stone, which was discovered in the patient's stool by the 
nurse and saved. That patient had a complete and typical 
history of gall-stones. Here the cKnical picture is incomplete. 
We cannot say with certainty that stones are either present or 
absent. A similar clinical history and negative physical findings 
are also sometimes present in atypical cases of gastric and duo- 
denal lesions, particularly ulcer, as well as in lesions of the gall- 
bladder. 

A chronic infection of the gall-bladder independent of the 
presence of stones produces, sometimes, much more serious 
constitutional conditions than we are prone to give it credit for. 
I will cite just one case, the patient a doctor from Oconto, Wis- 
consin. He had been having trouble for some little time with 
his digestion, together with epigastric pain and discomfort and 
great loss of weight — almost as much as in advanced phthisis. 
He never had a real colic and never any pain sufficiently severe 
to require the use of an anodyne. During the acute attacks 
he was sensitive to perpendicular percussion over the gall- 
bladder. When the attack had passed there was practically no 
discomfort to percussion over the gall-bladder. He was of the 
opinion, however, that the trouble was in his gall-bladder, and 
he was so concerned about it that he came down here for opera- 
tion. When we exposed the gall-bladder we found it pale at 
its cervix, — the type of gall-bladder which I showed you on 
Wednesday, — and white over its fundus. It was not distended, 
but it contained some seropurulent material in the cervix. 
There were no adhesions to it of the surrounding viscera. We 
merely drained the gall-bladder and he gained 30 or 40 pounds 
in weight in about as many days. There were no stones in 
that gall-bladder and there never had been stones, in all proba- 
bility, because he never had had a colic or jaundice or found 
stones in his stools. All he had was that type of low-grade 
infection which expresses itself by a change in the vasculariza- 
tion of the gall-bladder wall, an avascularity due probably to 
healed angiitis or to diffuse connective-tissue changes. 



IIo6 CLINICS OF JOHN B. MURPHY 

[Dr. Murphy made the usual right paramedian exploratory 
incision and exposed the gall-bladder to view.] 

Let me cover the gall-bladder with a towel, so that only the 
dome shows. What does it look like? It looks more like 
stomach-wall than like a gall-bladder because of that white 
infiltration of which I have already spoken. Whether there are 
stones present or not in addition need not cut any figure in the 
clinical manifestations of such a gall-bladder. A gall-bladder 
like this will produce clinical manifestations whether the presence 
of stones leads to additional symptoms or not. 

There are some other questions which we should like to ask 
about now. What was the etiology of this infection? Was there 
originally an acute gall-bladder lesion? Was there an ascending 
infection of the common and cystic ducts from a duodenal ulcer? 
Did she have originally an attack of typhoid fever, of which 
there is no account in the history? Is that history correct, doctor? 

Intern: She has never had any illness which resembled 
typhoid. 

Dr. Murphy: Did she have an appendicitis, then, which is 
the next most common cause of cholecystitis after typhoid? 

Intern: No. She has never had any pain in the lower ab- 
domen. 

Before opening this gall-bladder let us bring the stomach into 
the field and examine both the stomach and the duodenum to 
see if we can find any changes there which will throw light on 
this condition. She has a most pronounced hypertrophy of the 
pyloric ring. The ring is so thick that it feels almost like a 
tumor. But it is elastic and homogeneous and the peritoneal 
surface is perfectly normal. It is not a tumor — it is merely a 
hypertrophy of the pyloric musculature. There is nothing to 
be seen or felt in the stomach or duodenum which resembles an 
ulcer. 

I am looking over the lesser curvature of the stomach with 
special care, particularly the prepyloric portion, because 84 
per cent, of all the gastric ulcers occur in this region. There is 
no evidence at all of an ancient ulcer. The duodenum appears 
somewhat dilated, as you see here. It is certainly a large duo- 



CLINICAL TALKS ON DL^GNOSIS II07 

denum, but there are no adhesions on its surface to the surround- 
ing viscera. There is no stellate or radiating scar on its perito- 
neal surface to indicate the presence of an ulcer. The under 
surface of the duodenum, its pancreatic side, is also negative 
to palpation. The head of the pancreas also is not thickened. 
Since we can find no obvious trace of local causes in this region to 
account for the development of this recurrent cholecystitis, we 
must, therefore, assume that it had its origin in some systemic 
infection of such mild degree that it has escaped the patient's 
memory or does not seem to her of sufiicient significance to 
relate to us. Now we will see if there are stones associated with 
this gall-bladder infection or not. 

Let the record show that there are no adhesions of the sur- 
rounding viscera to the gall-bladder; that there is no evidence 
of a pericholecystitis present or past. Let the record further 
show that the gall-bladder does not empty with moderate pres- 
sure and that the gall-bladder is full of gall-stones. 

The presence of these gall-stones has nothing to do with 
the pathologic changes which we have noted in the wall of the 
gall-bladder. It is the preceding or accompanying infection 
which produced the changes. The infection can continue there 
with stones as well as without them, and probably the presence 
of the stones tends to prolong the infection. 

Let the record show that there are no stones impacted in the 
cystic duct. 

I am bringing this gall-bladder well up into the field, so that 
I may also bring the common duct into closer range. The 
patient has never had any jaundice; but we showed you on last 
Wednesday a case which illustrated how easily possible it is for 
a stone to be present in the common duct without producing 
jaundice. Such patients are apt to have a jaundice when the 
stone enters the common duct; but the jaundice does not con- 
tinue long, as a rule, unless the stone is large enough to plug 
the common duct completely. 

Let the record show that there is no stone in the common duct. 

[Dr. Murphy drew the dome of the gall-bladder up out of the 



II08 CLINICS OF JOHN B. MUHPHY 

wound, packed off the peritoneal cavity with tampons in the 
usual way, and opened the gall-bladder.] 

We will draw out the bile now and I want a culture made of it. 
There is a good deal of loose, gritty debris in the contents of 
this gall-bladder. There appears to be only one crop of stones. 
By that statement I mean to infer that the patient has had only 
one period of severe infection. These smaller stones, some of 
which I am bringing out with the scoop, have been arrested in the 
pockets of the mucosa of the gall-bladder and will come out later 
through the tube if I do not get all of them now with the scoop. 

[Dr. Murphy then sutured a rubber drainage-tube in the gall- 
bladder in the usual way and closed the abdomen.] 

In spite of all these gall-stones, this woman has never had 
any jaundice. She also has never had anything that one could 
really call a gall-stone colic. She had pain in the epigastrium 
and under the right costal border, but the pain was never colicky 
in character. If we had seen this patient in one of her acute 
inflammatory attacks, we could have made a positive diagnosis 
of cholecystitis with 96 per cent, of certainty. Any one can do 
it who will take the time and trouble to make the proper ex- 
amination. Why did I say that one could make this diagnosis 
with 96 per cent, of certainty? In 100 cases with great sensi- 
tiveness over the gall-bladder on perpendicular percussion there 
will be usually about four cases without lesions in the gall-blad- 
der. These four cases, as a rule, present very acute upper 
abdominal lesions which demand more immediate surgical relief 
than does an obstructed gall-bladder, and so, if one operates 
these cases thinking them to be acute gall-bladder lesions, the 
error is not expensive to the patient, but rather of advantage to 
him, since the operation allows us to make the correct diagnosis 
and at the same time to institute the immediate treatment 
usually urgently needed. These lesions are: Perforations of the 
duodenum and pyloric zone of the stomach; acute pancreatitis, 
and appendicitis where the appendix lies high up in the abdomen 
— a condition more common in children than in adults. This 
test on which I place such great reliance in acute gall-bladder 
lesions, — perpendicular percussion over the gall-bladder, — is 



CLINICAL TALKS ON DIAGNOSIS II09 

one which I have been using for a great many years. (See 
Clinics for June, 191 2, pp. 459 to 466.) In talking with Dr. 
Norman Bridge, of Los Angeles, on this subject he reminds me 
of his using the method long before I did; that is, he has been 
using it in the diagnosis of a variety of lesions besides gall- 
bladder troubles for determining that the affection is a circum- 
scribed lesion. To make the test, you lay the palm of your left 
hand fiat on the lower right chest-wall with all your fingers ex- 
tending beyond the costal border on to the abdomen. Then 
bend the middle finger so that its tip rests beneath the costal 
border at the tip of the ninth costal cartilage. Ask the patient 
to close the eyes and take a deep breath. Then, at the height 
of inspiration, strike that finger sharply with the other hand. 
The pain produced is severe if the gall-bladder is inflamed or 
distended. It is a strikingly effective and most practical test 
for the bedside. Putting your finger over the appendix and 
striking it in the same way with the other hand gives the gall- 
bladder patient practically no pain at all, although it gives the 
appendicitis patient an agonizing moment. That is the con- 
trast. You know, then, with practically 100 per cent, of cer- 
tainty, that the cause of the patient's trouble is an upper ab- 
dominal lesion, and with 96 per cent, of certainty that it lies 
in the gall-bladder. See how valuable this test is when you see 
such a patient as this woman in her acute attack. If you can 
make the test at this time, you can make the diagnosis. But if 
you are compelled to examine her in the free interval, you have 
only very slight grounds on which to base an opinion. See 
how important it is to say then and there, at the time when you 
are called to the bedside, what the lesion is! The three common 
lesions that one is likely to confound with a recurring inflamma- 
tion of the gall-bladder are: appendicitis, obstruction to the 
outlet of the kidney, and an infection involving the kidney. 
One often wants to be able at the bedside to make without 
hesitancy a positive diagnosis between these four conditions. 
One cannot do it if he is a *' machine diagnostician," is tied down 
to the x-ray machine and the microscope, and expects his roent- 
genologist and pathologist to make his diagnoses and do his 



mo CLINICS OF JOHN B. MURPHY 

thinking for him. When one has to deal with a gall-bladder, 
perpendicular percussion, as above described, usually settles the 
diagnosis. When it is an appendicitis, the sinking in of the hand 
on the left side of the abdomen and the comparative resistance 
to it on the right side, a sign brought out by a partner of Dr. 
Bridge and myself, old Dr. Edward Lee, is often the deciding 
factor. Dr. Lee always accentuated that sign. Then, finally, 
there is the fist percussion over the kidney posteriorly, in renal 
distention and inflammation. The "jack-knife reaction" of 
the patient to the pain caused gives one positive proof that the 
lesion lies in the kidney. These tests one can make then and 
there in a few moments at the bedside. Then you can say to 
the patient and his people with a feeling of positiveness which 
carries conviction that you know what is the matter. Re- 
member that when people do not accept your professional con- 
clusions, it is not always and entirely their fault. It is the ele- 
ment of doubt in your own mind that betrays itself to the people 
through some medium of which the doctor is often not aware, 
an intuition, if you wish to call it that, which nature has given 
Man for his protection. The people recognize that you are 
faltering, and they hesitate or decline to follow your line of 
action. If you are positive in your own mind concerning your case, 
they will follow your advice readily and they will do just what 
you are convinced is the right thing to do. One often hears the 
stock expression used by physicians, "The people would not let 
me do it." It is just as often the doctor's fault as the patient's. 

Visiting Doctor: What is the sign in appendicitis of which 
you spoke? 

Dr. Murphy: You stand on the right side of the patient 
and place the tips of the fingers over McBurney's point. Then 
press downward. In acute appendicitis the finger-tips will make 
practically no depression in the abdominal wall, whereas in the 
left lower quadrant of the same patient, by using the same 
amount of pressure, they may sink in clear down to the second 
or third joint. It is purely a test of muscular rigidity. 

Often in a relaxed abdomen if you will run your fingers across 
the shelf of the ilium you will feel a slender structure slip under- 



CLINICAL TALKS ON DIAGNOSIS I II I 

neath your finger-tips which you may think is the appendix. 
Then, when you open the abdomen and find the appendix lying 
three inches lower down than you thought you felt it, you are 
surprised and disappointed. I have been disappointed a good 
many times. Perhaps sometimes this apparent change of posi- 
tion is real and occurs as the result of scrubbing the abdomen, 
changing the patient's position, and starting up peristalsis. At 
other times, I am quite certain, it is the contracted lower ileum, 
which, when empty and spastic, may be no thicker than a foun- 
tain-pen or a large appendix, and so give rise to this surprising 
error. 



HODGKIN'S DISEASE 
By Dr. Charles L. Mix 



HISTORY 

Patient, male, aged seventy-two years, entered the hospital 
October 20, 19 14, with the following history: 

He had the usual diseases of childhood. He had smallpox 
at twenty years, and was sick for two months. Thirty-five 
years ago he had a small tumor removed from his foot. His 
family history is negative. 

The patient states that eight years ago he had a swelling the 
size of a hazelnut in the neck, one inch below the angle of the 
jaw. It was movable, not painful, gradually enlarged, and the 
glands in the neck began to swell. This condition slowly pro- 
gressed until he noticed his voice was becoming husky and he 
found difiiculty in swallowing. He also noticed that his trachea 
was being pushed to one side (left). This became very evident 
in January, 19 14, and the glands on the right side became pain- 
ful, tender to touch, and greatly swollen. The swelling subsided 
somewhat after three weeks. A section was made from the mass 
one week ago, and it was diagnosed as Hodgkin's disease. There 
is no other involvement of the glands except a slight enlargement 
of the glands in the right axilla. 



1 112 CLINICS OF JOHN B. MURPHY 

COMMENTS 

Dr. Mix: The first case which I show you is to be operated 
upon this morning by Dr. Murphy, the operation being for the 
purpose of getting a piece of tissue for microscopic examination. 

The interesting thing about this patient, who is now seventy- 
two years of age, is that the mass which started just beneath the 
ear on the right side is of eight years' duration. The patient 
states that it came about from an infection situated just beneath 
the right ear, at a point where the patient now shows a slight 
mark up>on the skin which is ahnost too small to be dignified by 
the name of scar. The patient may be perfectly right about this 
statement. It is often difficult to decide where the infection 
enters in cases of this sort. On examining the right side of the 
neck one can see a mass of protruding glands. On palpating it 
one immediately makes a very important discovery — that the 
skin is not adherent to the gland. In tuberculosis the skin is 
adherent; in Hodgkin's disease the skin is not adherent. This 
affords a reason for believing that the present case is not one of 
tuberculosis, but one of Hodgkin's disease. Furthermore, the 
eight years' duration is rather a certain indication of the truth 
of this diagnosis. Furthermore, there is in the right armpit an 
enlarged gland, but on examination of the left axilla and of both 
groins there is no evidence of any other enlarged lymphatic 
glands. It is impossible for us to palpate any enlarged mes- 
enteric glands or to entertain the belief that they are possibly 
enlarged. 

The important thing in this particular case is not so much 
the diagnosis, which is a comparatively simple matter as soon as 
a piece of tbsue is removed and studied. Indeed, the absolute 
diagnosis must be made by an excision of some of the timior mass 
and by a study of its sections. You find, when you look at one 
of these sections under the microscope, that there is a chronic 
lymphadenitis with an atypical endothelial hyperplasia. You 
will also find a proliferation of the stroma of the lymph-node, 
with a well-marked infiltration with eosinophile cells. There is, 
too, some increase of the connective tissue about the lymph- 
node, constituting a sort of perilymphatic sclerosis. 



CLINICAL TALKS ON DIAGNOSIS III3 

On examination of the blood in these patients there is usually 
either an increase or a decrease in the leukocytes. Usually in 
these cases there is a diminution of the polymorphonuclear cells, 
with an increase of the lymphocyte cells, particularly of the large 
mononuclear and transitional cells. Another feature of the 
blood-picture is a more or less well-marked basophilia and the 
presence of nimierous blood-platelets. They are more than usu- 
ally numerous in this disease; comparatively large ones have at 
times been found. 

In the last two years a good deal of attention has been given 
to the bacteriology of Hodgkin's disease and quite a good deal 
has been learned. The first well-marked theory in regard to the 
etiology of Hodgkin's disease was that advanced by Sternberg 
many years ago — ^in 1890. Sternberg believed that most of the 
cases of Hodgkin's disease were tuberculous. This has been 
proved to be false. In 19 10, that is to say, four years ago, 
Fraenkel and Much studied carefully the bacteriology of 13 
cases of Hodgkin's disease. They found that, by treating the 
excised nodes by the antiformin method, they were able to dem- 
onstrate in the specimens in all but one of the cases some bacilli, 
which looked very much like the tubercle bacillus, which were 
granular and Gram-positive, but which were not acid-fast. In 
every way they seemed to be exact tubercle bacilli with the 
exception that they were non-acid-fast. Fraenkel and Much 
looked upon these organisms as non-acid-fast tubercle bacilli, 
and thought they were identical with the ordinary tubercle 
bacillus existing in a non-acid-fast form. For a long time it was 
thought that these observations of Fraenkel and Much strongly 
supported Sternberg's tuberculous hypothesis. 

The next step in the history of the development of the etiology 
of Hodgkin's disease was taken by two German observers, Negri 
and Mieremet, who reported in 191 2, in the Centralblatt fur Bac- 
teriologie, that they had found in certain cases of Hodgkin's 
disease a diphtheroid bacillus which had a mild tendency to re- 
semble the ray-fimgus in that it grew in climips which some- 
times assumed branching forms, and sometimes assumed the 
shape of granular rods of considerable length, with a tendency 



1 1 14 CLINICS OF JOHN B. MURPHY 

to a clubbing of the ends, exactly as in the case of the ordinary 
diphtheria bacillus. The most striking fact about this particular 
bacillus, described by Negri and Mieremet under the name of 
Corynebacterium granulomatosi maligni, is its pleomorphism; and, 
as they describe it, it seems indeed to resemble the organism 
described in 1 910 by Fraenkel and Much. Like Fraenkel and 
Much^s organism, it is non-acid-fast, is Gram-positive, and re- 
sembles the tubercle bacillus in its tendency to granularion. 
All kinds of forms develop in different culture-media. Some- 
times they are merely short rods, sometimes they are long rods, 
sometimes they are almost spheric, sometimes they are thin, some- 
times they are comma-shaped, occasionally they are branched, 
frequently they are bipolar in their staining. After being sub- 
cultured a few times they are apt to assume the form of short 
chains resembling the streptococcus. In this latter respect the 
organism rather closely resembles the ordinary bacillus of diph- 
theria and has, therefore, been given the name of the diphtheroid 
bacillus of Hodgkin's disease. 

Though this work of Negri and Mieremet antedated all other 
discoveries in point of announcement, it does not actually ante- 
date our American investigations in point of time. In this 
country two physicians have long been working on the problem 
— Bunting and Yates. As soon as the article of Negri and 
Mieremet appeared in the Centralhlatt fiir Bacteriologie, Bunting 
and Yates hastened to hand into the Archives of Internal Medi- 
cine a paper entitled, "The Cultural Results in Hodgkin's 
Disease," submitted for publication June 5, 19 13, and published 
in the August issue of last year. In this article Bunting and 
Yates, after calling attention to the work of Negri and Mieremet, 
published a preliminary statement as to the cultures which 
they had made in five cases of Hodgkin's disease. In three of 
these cases they secured pure cultures of a pleomorphic diph- 
theroid organism. In the other two cases they found the or- 
ganism, but they were unable to secure it in pure cultures. In 
the sixth case the organism, like those in the five cases studied, 
was obtained from Peyer's patches and mesenteric lymph-nodes 



CLINICAL TALKS ON DIAGNOSIS III5 

in a young girl of six years who died in a severe attack of vomit- 
ing, apparently without a diagnosis. 

Bunting and Yates also published in the Journal of the Ameri- 
can Medical Association of November 15, 19 13, a preliminary 
note in regard to the etiology of Hodgkin's disease, in which 
they made the claim that they had succeeded in producing en- 
larged lymph-nodes in a monkey, Macacus rhesus. These 
lymph-nodes, when studied, showed the same histologic find- 
ings as the lymph-nodes of Hodgkin's disease in the human 
individual. Though they did not claim that they actually pro- 
duced Hodgkin's disease in the monkey, they did claim that, by 
repeated injections, they brought about a remarkable enlarge- 
ment of a single group of lymph-glands, which showed histologic 
changes identical with those found in Hodgkin's disease in man. 

Bunting and Yates, in their article in the Archives of Internal 
Medicine, did not like the name chosen for the diphtheroid 
bacillus by Negri and Mieremet, and suggested Corynehacterium 
Hodgkini as a substitute. It would seem to me that this latter 
designation is a considerable improvement on the former, be- 
cause it immediately explains itself. 

The last important consideration of this general subject 
is embodied in a paper on ^'The Etiology and Vaccine Treat- 
ment of Hodgkin's Disease" by Billings and Rosenow, of Chicago. 
Rosenow, in studying the lymph-nodes of 12 cases, obtained in 
pure culture in three of them the diphtheroid bacillus of which 
we have been "Speaking. In the other nine it appeared in con- 
junction with a staphylococcus. On growing these diphtheroid 
bacilli, the same pleomorphism described by Much and Bunting 
and Yates was noted. It was also observed that the older the 
lymph-nodes, the more organisms it contained, especially the 
staphylococci; the more recently involved lymph-nodes showed 
fewer organisms, and in these organisms a relatively larger pro- 
portion of bacilli than of staphylococci. Rosenau was of the 
opinion, on studying his cultures further, that the staphylococci 
which he found were probably the pleomorphic forms of the 
bacillus, possibly due to its longer habitat in the older glands. 

The idea occurred to Rosenow of preparing a vaccine from 



IIl6 CLINICS OF JOHN B. MURPHY 

these bacilli. It is not necessary for us to go into the technic 
which he adopted. Suffice to say that he prepared an autogenous 
vaccine which he gave in the cases reported in comparatively 
small doses, beginning with from 5,000,000 to 10,000,000, and 
gradually increasing to a maximum of 100,000,000. The vaccine 
was given subcutaneously every five to seven days. It was not 
given intravenously. In the non-febrile patients only a slight 
reaction followed. In one febrile patient an increase of temper- 
ature took place to 107° F. Rosenow and Billings report in six 
of their 12 cases a uniform and relatively rapid decrease in the 
size of the lymph-nodes. It must be said, however, that all 
these cases with one exception were simultaneously treated with 
the jc-ray. It is, therefore, perhaps somewhat difficult to say 
whether the vaccines were responsible for the entire improve- 
ment or whether one it:-ray exercised a marked effect. 

Now, what do we want to do with this patient? Evidently 
the proper thing to do is to remove a piece of glandular tissue, 
taking, if possible, some of the older glands involved, and then 
some of the newer glands, for the purpose of preparing from it 
cultures with the idea of subsequently making a vaccine. It is 
our purpose to make an autogenous vaccine in the case of this 
patient and to administer it to him with the hope of curing him. 

We have still another of these cases which I will now show 
you. 

HISTORY 

Patient, male, aged twenty-nine years, entered the hospital 
October 6, 19 14, with the following history: 

Had the usual diseases of childhood. Had diphtheria thirteen 
years ago; was sick two weeks; no complications. His family 
history is negative. 

Present trouble came on September 5, 19 14, when the patient 
noticed some pressure in the throat, just above the clavicle, to 
the right and in the midline. This was more marked upon 
swallowing. His breathing seemed affected and his voice gradu- 
ally became husky. One week later, September 12, 1914, he 
noticed a swelling in the neck in the posterior triangle of the right 
side. He had no evidence of external swelling before this. This 



CLINICAL TALKS ON DIAGNOSIS III7 

grew rapidly, and he now feels a mass the size of a large hen's- 
egg and above this a mass the size of a pigeon's-egg. On Sep- 
tember 23d his neck measured 20 inches. On September 25th 
it measured 21 inches. 

He had no chills or fever prior to this trouble, no tonsillitis, 
sore throat, or running ears, but he had a slight cough for one 
week preceding. He had no trauma to the part. The patient 
has had no loss of weight, no weakness. He noticed a swelling in 
the right axilla October 5, 1914. 

These tiunor masses are not painful, and apparently not 
tender to pressure. He has not complained of tenderness or 
swelling in the abdomen. There has been no pigmentation of 
the skin or enlargement of the glands in the groin. The tumor 
in the neck does not move upon swallowing. The thyroid seems 
free. The spleen is not enlarged and not tender. The patient 
had a diarrhea from September 25, 19 14, to October i, 19 14, and 
since then he has been constipated. The patient shows no 
anemia. He had gonorrhea six years ago. He denies a history 
of lues. 

COMMENTS 

Dr. Mix: The remarkable thing about this case is the his- 
tory of the onset of his symptoms. The first thing which the 
patient noticed, as he told me yesterday, was that his windpipe 
was pushed over to the left. This happened before his voice 
began to be husky and before he had any difficulty whatever in 
swallowing. This would seem to indicate that the onset of his 
trouble was from within. One is inclined to blame the tonsil 
as being the source of the involvement. Subsequently there 
was considerable disturbance of his swallowing, his breathing 
became affected, and his voice became husky. It was not until 
he had these symptoms for a week that he noticed the swelling 
in the right side of his neck. The swelling increased with re- 
markable rapidity, so that by the twenty-third of September his 
neck measured 20 inches in circiunference and by the twenty- 
fifth of September 21 inches. In the case of this patient the 
diagnosis has already been made microscopically, a portion of 
the gland already having been removed and studied. Cultures 



IIl8 CLINICS OF JOHN B. MURPHY 

have been made from this gland, and an autogenous vaccine of 
the diphtheroid bacillus will be administered to him in case our 
cultures are positive. 

[Note. — In the first case, a mixed growth was obtained of 
streptococci, staphylococci, and the diphtheroid bacillus de- 
scribed by Bunting and Yates. A vaccine was prepared and 
has been administered, but thus far without marked improve- 
ment. 

In the second case the diphtheroid bacillus was obtained in 
pure culture, and a vaccine prepared according to Rosenow^s 
method. This case showed some improvement after the second 
injection. — Ed.] 



AUTO-SENSITIZED AUTOGENOUS VACCINES 
(PRELIMINARY REPORT) 

By Philip H. Kreuscher, M.D., of Dr. Murphy's Staff 



One of the most objectionable features of vaccine therapy is 
the local and general reaction which follows the injection of even 
small amoimts of attenuated or dead bacteria. Our best efforts 
to overcome this objectionable feature have so far met with Kttle 
success. The fact still remains that the reaction following the 
injection is so great that the amount must be so limited that the 
beneficial effect has not proved satisfactory, and the chnician is 
now face to face with the problem of eliminating, as far as possible, 
the constitutional and local reactions. 

Besredka has demonstrated that much larger amounts of 
bacteria can be given if they have been previously saturated with 
immune serum. We have undertaken in this new variation to 
eliminate reactions which follow the injection of ordinary auto- 
genous vaccines. 

The pathogenicity of the organism must be obtained and 
maintained at the highest possible point. 

On October 6th Dr. Murphy suggested a modification of our 
present technic in making our vaccines. He suggested that the 
blood of the patient be used as a culture-medium upon which the 
organisms to be used in the preparation of the vaccine should be 
grown. This gives the bacteria as nearly the same medium for 
growth as is present in the patient from whom the organisms are 
taken. Dr. Murphy reasoned that inasmuch as the auto-borne 
transplant has yielded practically loo per cent, perfect results, 
the auto-medium for bacteria should be the logical one to use in 
the preparation of the autogenous. We believe that we are the 
first to make use of this principle in connection with vaccine 

VOL. Ill — 70 iiig 



II20 CLINICS OF JOHN B. MURPHY 

therapy. (In our last vaccine article, which appeared in the 
Interstate Medical Journal for November, 19 14, we were using 
this new procedure in the preparation of the autogenous vac- 
cines.) 

The next logical step was to attempt auto-sensitization of the 
vaccine, as suggested by Dr. Sweek. The patient is consider- 
ered to have a certain amount of inomunity against invading or- 
ganisms. Instead of immunizing an animal to procure the im- 
mune serum, the patient's own blood-serum is used. 

The use of the patient's blood as a growing medium was 
found to have a marked effect in keeping the organism virulent 
and up to its maximum pathogenicity. The technic of the pro- 
cedure is as follows: 

Twenty c.c. of blood are withdrawn from the patient's veins, 
and immediately i c.c. is introduced into each one of 20 ascitic 
agar slants. The tube is then slanted, and the blood is allowed 
to cover and float upon the entire surface of the ascitic agar for 
one minute. The tubes are then placed in the incubator in an 
upright position for twenty-four hours. The blood coagulates 
at the bottom of the tube, and a few drops of serum are expressed 
by the contraction of the clot. If any of the tubes have been 
contaminated, a growth will be apparent upon them at the end 
of twenty-four hours, and these are discarded. The tubes free 
from bacterial contamination are now ready for inoculation . The 
organism is secured from the patient, and the tubes inoculated 
simultaneously. They are then incubated twenty-four hours. 
At the end of twelve hours one is removed and a tube of plain 
agar is inoculated from this. At the end of the twenty-four 
hours the tubes are removed and a smear is made and examined 
microscopically. The single tube of plain agar is allowed to 
remain twelve hours, so as to complete its twenty-four-hour 
growth. The blood tubes are next placed in the ice-box, ready 
for the next step. 

The second step is to secure 60 c.c. of blood from the patient. 
Thb is allowed to clot at room temperature, and is then placed 
on ice for twelve hours. The clear serum is decanted and placed 
in a flask.. One c.c. is removed and placed aside. The remainder 



AUTO-SENSITIZED AUTOGENOUS VACCINES 1 121 

is then inactivated at 57° C. The i c.c. placed aside is not in- 
activated, but is used in making a precipitation test on the 
growth contained in the plain agar tube. If this is positive, the 
entire number of tubes are washed clean of the surface growth. 

Into the first tube 5 c.c. of 0.7 per cent, salt solution is poured. 
The growth is gently rubbed from the surface of the medium with 
a round glass rod. The blood-clot in the bottom of the tube must 
not be disturbed. The contents of the tube are then poured from 
one tube into another, and the same procedure repeated until all 
of them are washed clean of any visible growth. This bacteria 
emulsion is next placed into the inactivated patient's serum and 
incubated for twenty-four hours. At the end of this period the 
culture is removed and a smear is made for comparison with the 
first smear. The bacteria in the emulsion are then counted, and 
the number per cubic centimeter is ascertained. They are then 
sealed in ampules and placed in the water-bath at 60° C. for one 
hour. At the end of one hour they are removed and placed on 
ice. One capsule is opened, and the contents are placed on agar 
tubes to test for the presence of living organisms. An additional 
precaution is taken, as in ordinary vaccines by animal inocula- 
tions. One c.c. is injected intraperitoneally into a guinea-pig 
and one into the ear vein of a healthy rabbit. Sufficient time is 
allowed for the animal observation. If no growth is found on 
the control tubes and the animals are not affected, the vaccine is 
ready for use. 

Bacteriologic asepsis throughout is essential for success. A 
careless operator will invariably contaminate the tubes or serum, 
and find that at the final test he must discard the vaccine on 
account of contamination with spore-forming organisms. 

The above technic, while exacting and difficult, has proved to 
be of value in eliminating the undesirable element in vaccine 
therapy to a considerable extent at least. The number of bac- 
teria can be enormously increased without the great local and 
general reaction. We have thus succeeded in injecting 30,000,- 
000,000 of mixed streptococci and staphylococci without any 
severe local or constitutional reaction. 

We have up to date made vaccines from eight patients suf- 



1 122 CLINICS OF JOHN B. MURPHY 

fcring from various lesions. The above technic, as worked out 
by Dr. Sweek, was followed in every detail. 

Case No. i. — Mr. B. Compound fracture of the tibia into 
the ankle-joint and cellulitis of the leg. Auto-culture medium 
was made without contamination and medium inoculated with 
pus from wound forty-eight hours later. Vaccines were prepared 
and proved perfect by the guinea-pig and culture tests. This 
patient has had four injections. 

Case No. 2. — Mr. D. Osteomyelitis of the femur. Same 
procedure as above. This patient has had two injections. 

Case No. 3. — Mr. McD. Ischiorectal abscess and epididy- 
mitis. Under treatment now. 

Case No. 4. — Mrs. V. Ulcer of the cornea and multiple in- 
fected embolic ulcers of the body. 

Case No. 5. — Dr. G. Metastatic deforming arthritis follow- 
ing nasopharyngeal infection and chronic purulent bronchitis. 
Vaccines were made from the above-named foci of infection. 

Case No. 6. — Mrs. Z. Metastatic arthritis from nasopharyn- 
geal infection. Vaccines made from pus discharged from nose. 

Case No. 7. — Mrs. D. Colon-bacillus infection of the uri- 
nary bladder. Culture taken from urine. 

Case No. 8. — Mrs. M. Acute persistent arthritis with ef- 
fusion following a nasopharyngeal and sinus infection. Pus 
taken from the nasopharyngeal discharge. 

A detailed report of our results and conclusions, together with 
the theoretic conditions, will be published in a later article. 

From our experience up to the present time we would con- 
clude: 

1. That this method has eliminated the severe local and con- 
stitutional reactions which have been so common and annoying. 

2. That large doses of vaccine can be given with very little 
or no reactions. 

3. That if autogenous vaccines have given good results, the 
auto-sensitized vaccine made from bacteria grown on the pa- 
tient's own blood should very nearly approach the ideal. 



IMPACTED FRACTURE OF EXTERNAL TUBER- 
OSITYOF TIBIA.— CHRONIC ARTHRITIS AND 
GREAT PAIN PRODUCED BY THE PRESSURE 
OF THE INTERCONDYLOID TUBERCLE OF 
TIBIA AGAINST ARTICULAR SURFACE OF 
FEMUR.— ARTHROTOMY.— EXCISION OF IN- 
TERCONDYLOID TUBERCLE 



HISTORY 

The patient, a married man aged forty-five, entered the 
hospital with the following history: 

On October 4, 191 2, the patient fell off of a scaffolding, which 
was about four and a half feet high, striking his whole weight 
on his left knee. He could not bear any weight on the knee 
when he arose. He called a doctor who put him to bed and kept 
hot apphcations on the knee. He remained in bed thirteen days. 

Immediately after the injury the knee became swollen to 
almost twice the normal size, but did not become red. It was 
very painful and tender. He tried to use the knee after thirteen 
days had elapsed, but found that he could not bear much weight 
on the leg. The doctor called once a week for five months follow- 
ing the injury, and at one time drew some fluid out of the inside 
of the knee with a needle. In March, 1913, the patient employed 
another doctor, who at once put extension on the leg. This was 
kept on for eight weeks, then removed, and a plaster cast put 
on from the foot to the hips. The patient walked around with 
the limb encased in the cast. The cast was removed at the end 
of one month. The knee was still swollen, but not tender ex- 
cept when the patient attempted to bear weight on the leg. He 
received no further treatment, but hobbled around on the leg 
imtil October, 19 13, when, of his own accord, he went to bed 

1 123 



1 1 24 CLINICS OF JOHN B. MURPHY 

and stayed there for four months (until February, 19 14). Then 
he got up and found the knee no better, but in about the same 
condition as at present. 

At no time since the accident has he had any chills or fever 
that he knows of. He never has had any cough or night-sweats. 
There is no apparent deformity of the leg or atrophy about the 
knee-joint. One brother died of tuberculosis. The family his- 
tory is otherwise negative for tuberculosis. 

COMMENTS AND OPERATION 

Dr. Murphy (April 30, 19 14): When was the extension first 
put on the knee? 

Intern: About five months after the accident. 

Dr. Murphy: I want to show you the ic-ray picture of this 
case because, although it clearly shows pathologic changes to be 
present, yet even with its aid it is difficult to arrive at a positive 
conclusion as to the exact diagnosis of the case. Note the de- 
velopments following the primary trauma. It is not clearly 
stated that the swelling ever went down after the initial injury. 
With tuberculosis it is the rule that the original trouble entirely 
subsides, the swelling disappears, and the fluid in the joint also 
disappears. Then, at the end of three or four weeks, depending 
on the age of the patient, come the manifestations of the disease. 
That is the typical onset of tuberculosis. The patients seem to 
recover from their primary trouble, are apparently well, and 
then in some three or four weeks, depending on the age, — in 
children, in from three to five weeks, — they commence to limp; 
first a little, then more. If the patient's history is correct as 
read, then he has had a continuous trouble dating from his 
trauma, without any interval of apparent recovery, and, there- 
fore, he must have some lesion other than a tuberculosis, per- 
haps a fracture, perhaps a metastatic infection, but not a tubercu- 
losis of the knee, in all probability. 

I wish to call your attention to the pronounced deformity 
which exists in the tibia, visible on examining the patient physi- 
cally as well as in the «-ray plate. I am inclined to believe 
that this -deformity was the direct result of his primary trauma. 




Fig. 354. — Impacted fracture of the external tuberosity of the left tibia. 
Anteroposterior radiogram. The deformity caused by the impacted fracture is 
only vaguely indicated in the plate. The interosseous interval in the joint is 
narrowed and there is slight "lipping" of the joint margins, the expression of the 
low-grade arthritis which develops in these joint fractures in the course of time if 
they are not corrected. 



1 125 



FRACTURE Or TUBEROSITY OF TIBIA 1 1 27 

He fell and fell heavily, striking his whole weight on the extended 
knee. He was unable to walk for thirteen days, but then got up 
and began to go around. He had repeated aspirations of the 
joint made. That fact does not mean much of anything, be- 
cause either a traumatic synovitis or a tuberculosis of the knee 
could have produced an effusion. If this condition should prove 
to be tuberculosis, it must be tuberculosis of the bone and not of 
the joint. Tuberculosis primary in the synovial membrane is 
rare at all ages, but exceptionally so in the adult. If that story 
is correct, as the intern read it, I should have to say that this 
condition is not a tuberculosis. This operation may be con- 
sidered largely exploratory. 

A tuberculosis of the knee primary inside the joint, which 
is a rare lesion, requires excision of the joint. Adult patients 
will never get well under any other treatment. One wastes good 
time trying to treat bone and joint tuberculosis of adults on the 
expectant plan. The line of treatment is an entirely different 
matter in children. There you can encourage ankylosis by im- 
mobiHzation and rest. This will probably be the treatment of 
tuberculosis so long as we are unable to overcome it with tuber- 
cuHn. The location of the tuberculous focus close to the articular 
surface of the bone is a favorable one in the child. An ankylosis 
will usually develop, but the epiphysis is not destroyed and the 
limb continues to grow. Then, when the patient reaches adult 
life, one can perform an arthroplasty on the ankylosed joint and 
give him a movable joint. In that way one gives the patient 
ultimately a good limb. 

One most easily cures the tuberculosis in a child by produc- 
ing an ankylosis. In place of putting the patient in an ambula- 
tory splint and encouraging walking, he should be put to bed with 
extension on the limb. Try to overcome the tuberculosis by 
the usual, well-recognized general and local measures; but, above 
all, dress the limb so that it will become ankylosed in a good posi- 
tion, that is, in complete extension. 

Osseous tuberculosis which occurs later in life often follows 
a traimia. What happens with the trauma? The trauma in- 
jures the epiphyseal line, usually on the joint side — rarely, if 



1 128 CLINICS OF JOHN B. MURPHY 

ever, on the shaft side. Bone tuberculosis is abnost uniformly 
an epiphyseal disease, practically never a shaft disease, in this 
country. In Scotland, where people live much on oatmeal and 
milk, there is a t^-pe of bone tuberculosis which occurs in the 
shaft. I beheve it is bovine tuberculosis. At any rate, its be- 
havior is different from the tuberculosis of this country. Per- 
haps the culture-medium is different, and thus influences the 
development of the organism, as Rosenow has shown in the case 
of Streptococcus viridanSj the specific pathogenicity of which is 
altered if you change the culture-medium. The clinical fact 
remains that the Scotch have shaft tuberculosis. I have not 
seen three cases of shaft tuberculosis in my whole life, so far as 
I can remember, in spite of. the enormous number of bone and 
joint tuberculosis cases which have come under my observation 
in the Cook County Hospital, the Alexian Brothers' Hospital, 
and here at Mercy Hospital. Not three! That shows about 
how frequent shaft tuberculosis is in Illinois. 

[Incision.] 

Now you can see that there is not that thickening here of 
the joint serosa which one finds in a tuberculosis of the knee, 
nor that thickening of the capsule. It is the thickening which 
one finds due to some mechanical disturbance of the articulation: 
it is not the marked thickening of a tuberculosis. 

In this region there is great vascularization, as you can see 
readily from the copious bleeding which we are now controlling. 
I am making my incision with a view to having it ample and 
properly placed in case we should decide that a reconstruction 
of the joint is necessary. In opening the joint we shall split the 
ligamentum patellae and cut half of it high and half of it low. 
That incision will give us free access to the upper end of the tibia, 
and allow us to excise the same if we wish. The ligament will 
also, when reunited and overlapped, serve to protect the tibial 
defect from subsequent injury. 

There is an area in the upper end of the tibia which in the 
ac-ray plate looks like an impacted fracture. The impression 
which I get of this focus, now that I have cut down on it, is that 
it is aa impacted fracture of the external condyle. I am niak- 



FRACTURE OF TUBEROSITY OF TIBIA 1 1 29 

ing a somewhat better exposure of it. I am pretty certain now 
that it is an impacted fracture. As a result of the depression of 
the external condyle, all the pressure of the femur has been 
thrown on the sharp intercondyloid ridge, with the consequence 
that there has been considerable intra-articular irritation, which 
gives the appearance of a low-grade arthritis. I am turning the 
knee around to you, so that you can see how the external con- 
dyle is entirely out of position, and lies much lower than the 
internal condyle. Now you can see the wisdom of entering the 
joint in this exploratory arthrotomy in such a way as to be able 
to reconstruct the joint, if necessary. We must remove the 
intercondyloid tubercle. You will remember I stated that the 
intern's history of the case spoke very decidedly against the 
presence here of a tuberculosis, and you can see now that my 
statement was fully justified. That shows the great value of a 
clinical history written in accurate consonance with the facts of 
the case. The conclusions which we drew from the x-ray plate 
in regard to the probability of an impacted fracture are also 
shown to be fully justified. 

Let the record show that the anatomic findings corresponded 
with the x-ray picture, and that our plan of operation — to open 
the joint in such a way that we could conserve or reconstruct it, 
according to the changes found present — was based on correct 
considerations; that we removed the intercondyloid tubercle 
which was pressing against the intercondyloid ridge, and thereby 
keeping up a continued low-grade inflammatory condition. 

Let the record further show that a portion of the internal 
semilunar cartilage was removed, as it had been torn. 

You will note the difference between the thickness of this 
fibrous capsule of the knee and the fibrous capsule in the case 
we showed you yesterday. Those of you who saw it will re- 
member the one yesterday was almost as thin as paper. This 
one is as thick as calfskin, owing to the chronic inflammatory 
changes present. Now we have restored that joint to normal, 
except we have taken off the intercondyloid tubercle of the tibia 
that was pressing against the articular surface of the femur. 
We have not had to put on a single ligature. We have not 



1 130 CLINICS OF JOHN B. MURPHY 

touched that wound with anything which previously had touched 
the gloved hand, not even with any part of the instruments where 
they had touched the hand. If you have acquired that technic, 
you are pretty safe in doing bone and joint work. A Buck's 
extension with a weight of 15 pounds will be applied as soon as 
the patient is returned to his bed. 

One of the most instructive lessons to be learned from this 
case is the great significance of a good clinical history. You 
will remember that until we opened up the knee we had no ade- 
quate explanation for the recurrence of the pain with each en- 
deavor to walk. Now we know that the recurrence of the pain on 
walking was due to the pressure of the intercondyloid tubercle 
against the sensitive articular surface of the femur. 

We now put on the dressing. We shall keep on the Buck's ex- 
tension with a weight of 20 pounds during the entire reparative 
process, probably about six weeks in all. At the end of that 
time we shall put on a straight external splint, which later will 
be provided with a shoe. The capsule of the joint will unite in 
that time, and the patient will have motion preserved in the 
joint without pressure or pain. He agreed to a stiff joint 
on the condition that it be without pain. We shall now be 
able to give him a better result than we promised. We have 
records now of a number of cases of this same type with an 
impaction of the external or internal condyle, most of them in 
older people, but at least one in a young individual. I have left 
enough of the intercondyloid ridge to keep the joint balanced 
and to keep it from luxating — about the same amount, in fact, as 
we use in reconstructing the joint in performing an arthroplasty. 
The failure of joint reconstructions of many operators was due 
to the fact that they did not retain the normal conformation of 
the joint, and that the joints, therefore, luxated laterally. One 
of the points which we brought out in the very early days of ex- 
cision of the knee was the necessity of reconstructing it to corres- 
pond to its normal conformation. 

We have a patient in the hospital now whom we operated 
fotir or five days ago because of an impacted fracture of the exter- 
nal condyle of the tibia. I freed the impacted condyle, replaced 



FRACTURE OF TUBEROSITY OF TIBIA 



II3I 



it, and nailed it back into position. This was done months after 
the fracture had occurred. She has not had an unpleasant symp- 
tom since the operation. 

[Note. — The wound healed by complete primary union. 
The patient was kept in bed between four and five weeks with 
15 pounds extension. He was out of bed at the end of six weeks 
with a leather support to the knee. He left the hospital June 
6, 1 9 14, still wearing the support. — Ed.] 



SARCOMA OF THE RIGHT TIBIA.— EXCISION. 
—TRANSPLANTATION OF BONE.— SUBSE- 
QUENT FRACTURE OF THE TRANSPLANT 
AND DEVELOPMENT OF A PSEUDARTHRa 
SIS.— SECONDARY TRANSPLANTATION OF 
BONE 

mSTORY 

The patient, a girl fourteen years of age, entered the hospital 
November 12, 191 1, with the following history: There is no 
cancer in her family. The patient's present trouble began about 
three years ago, in 1908, when she fell off a porch railing, a dis- 
tance of about five feet, injuring her right leg slightly. She 
paid no attention to the injury at the time, and the leg seemed 
perfectly well until about three or four months later, when she 
noticed, on running or jumping, a slight pain in the right leg just 
below the knee-joint. Several weeks later — she does not know 
how many — a point just below the knee became sKghtly swollen. 
She paid no attention to this swelling, but continued at school 
as usual. 

About one and one-half years ago, in 19 10, while at play she 
twisted the right leg, causing a pain so severe that she was forced 
to He down on the spot for several minutes before she could get 
up and walk to her home. The leg rapidly became worse, was 
very painful, and considerably swollen just below the knee. One 
week after this injury a physician put the limb in a cast but 
allowed the patient to walk about on crutches. She remained 
in about this same condition for seven months, making very little 
complaint and having pain only when putting weight on the leg. 

About one year ago — in 1910 — the cast was removed, some 
six months after it was applied, and the patient was able to walk 
with the aid of crutches, as she has continued to do up to the 

1 133 



1 134 CLINICS OF JOHN B. MURPHY 

present time. During the past year her leg has remained con- 
siderably swollen just below the knee, particularly on the inner 
side, and there is tenderness when she presses at this point. It 
hurts her when she walks on the leg, but when she is quiet she 
has no pain. During the entire course of the trouble she has 
never had any chills, fever, nausea, or vomiting. Her general 
health has been good. She has had no night-sweats or loss of 
weight. 

OPERATION: EXCISION OF THE SARCOMA. IMPLANTATION OF 

A BONE GRAFT 

The patient was operated November 14, 191 1. Dr. Murphy 
made a longitudinal incision over the timior below the right 
knee. The tumor was separated from its surrounding structures, 
from the tibialis anticus muscle, and, above, from the external 
popliteal nerve. The periosteum was left attached to the tumor. 
The patellar ligament was cut above. The tissues were divided 
beyond the area which was diseased. The articular surface of 
the tibia was sawed off and preserved. The soft tissues were 
separated from the posterior portion of the tibia, leaving the 
periosteum intact with the tumor. A piece of bone exactly $}^ 
inches long, including the tiunor and the upper part of the tibia, 
was sawed off and removed. 

A longitudinal incision was then made over the inner surface 
of the left tibia, and from the anterior surface of the tibia a piece 
of bone, 7>^ inches long, was removed, together with its peri- 
osteum. The woimd over the left tibia was closed with sub- 
cutaneous catgut sutures and the skin with silkworm-gut and 
horsehair. 

This piece of bone, 7>^ inches long, was used to fill the defect 
produced by removing the tumor and upper tibia from the right 
leg. The graft was driven into the medulla of the shaft of the 
tibia below and held in place and prevented from penetrating 
deeper into the medulla of the shaft by a wire nail driven through 
the graft where it entered the shaft. The upper end of the trans- 
plant was nailed to the upper articular portion of the right tibia, 
which was preserved when the tumor was excised. The sur- 




Fig. 355. — Chondromyxosarcoma of the upper 
!nd of the right tibia. Anteroposterior radio- 
ram made before operation. Note the substitu- 
ion of tumor tissue for bone at the inner side of 
he upper tibial diaphysis. The tumor mass 
hrows very little shadow as compared with the 
one. An outward bowing of the upper end of the 
ibia is thus produced, which is more apparent 
^lan real. 



Fig. 356. — Chondromyxosarcoma of the upper 
end of the right tibia. Lateral radiogram made 
before operation. The areas of lessened density 
are the areas of sarcomatous infiltration. Note 
that the tumor in the radiogram appears to be con- 
fined to the diaphysis of the bone entirely, and looks 
not unlike a benign chondroma. Benign tumors 
originating in the diaphysis of a long bone practically 
never pass the epiphyseal line in children, or the 
line of the epiphyseal scar in adults. Malignant 
diaphyseal tumors, however, show no such limi- 
tation and pass the epiphyseal line frequently; 
in fact, quite regularly. This radiogram, the de- 
tails of which are not sharp because the patient 
moved while it was being taken, shows no invasion 
of the epiphyseal line, whereas the tumor specimen 
removed at the operation shows a well-marked 
invasion. Probably a better radiogram would also 
have shown this imi)ortant detail. 



VOL. Ill — 71 



"35 




J''K- 357- — Sarcoma of the right tibia. The excised sjxjcimen has been siiwed 
in halves longitudinally, the better to show the extent and manner of invasion of 
the lx)ne. Note the evident medullary origin of the tumor and the thin layer of 
cortex still separating the tumor from the soft parts. The line of division of the 
shaft of the tibia appears to pass through healthy bone well beyond the tumor zone. 



1 1.^6 



SARCOMA OF THE RIGHT TIBIA II37 

rounding muscles and fascia were sutured over the transplant 
with phosphor-bronze wire. The Hgamentum patellae was 
sutured to the muscle and fascia. The wound was closed with 
silkworm-gut and horsehair without a drain. 

Examination on November 28, igii, two weeks after the opera- 
tion, showed complete primary union of both wounds with the 
production of new bone already under way to fill out the defect 
in the left tibia. No suppuration appeared at any time, either 
then or subsequently. 

Examination on January 16, igi2, showed a considerable 
voluntary range of motion, both of flexion and of extension, in 
the right knee. The internal malleolus could be rotated over an 
arc four inches in length. The excised portion of the right tibia 
has been entirely reproduced. The right patella is movable to 
the normal extent, and lies in proper relation to the condyles. 
The left tibia has returned to its normal size and contour. 

SECONDARY TRANSPLANTATION OF BONE 

COMMENTS AND OPERATION 

Dr. Murphy (June 13, 19 14): It is five and one-half years 
since the onset of the patient's trouble. The history of the onset 
shows that the pain passed off after the initial injury, and the 
patient seemed completely well for the next four months. Then, 
after this free interval, further symptoms developed. Late 
secondary trouble after an injury to a joint means usually, in a 
child, either tuberculosis or sarcoma. Entirely different is the 
course of impacted fractures involving joints. Such injuries 
are not recovered from immediately, but continue to annoy the 
patient without interruption. They have no initial "free 
interval. '' This patient completely recovered from the effects of 
her first injury and was apparently perfectly well for the next 
three or four months. After that time her knee began to trouble 
her again and, gradually, more and more as time passed. 

We have recently had a very similar case — a patient who 
came to us from Canada (see Clinics for August, 19 14). He was 
a grain inspector. His assistant threw a bushel sack of grain to 



1 138 CLINICS OF JOHN B. MURPHY 

him and threw it too high, so that in catching it the patient 
hyperextended his arm and twisted his right shoulder. The 
pain thus produced lasted only a day or two and resulted in no 
disability. Three weeks later he suffered another injury. He 
tripped on a cable and, throwing his hands back to save himself 
from falling, he strained his right shoulder again in practically 
the same way, producing a second time pain, but, again, no 
disability. He came to us from his last doctor with the diag- 
nosis of a fracture of the neck of the humerus. This diagnosis 
was correct; but the doctor's assumption that the fracture came 
from one of these two injuries was incorrect, because the patient 
had continued his regular work as grain inspector after both 
accidents without suffering any functional incapacity, a feature 
of the history which the doctor did not take into sufficient ac- 
count. The patient worked at full capacity after each of these 
accidents. Therefore, his fracture must have developed at a 
subsequent time. It was a pathologic fracture due to a sarcoma 
of the head and neck of the right humerus, the sarcoma being 
p>erhaps caused by his primary injury. Two doctors who saw 
the patient previous to the development of the pathologic frac- 
ture were greatly blamed by him for not diagnosing the break; 
but they were not at fault for not recognizing a fracture, because 
there was no fracture produced by either of the first two injuries. 
They were both at fault however, for not having an o^-ray plate 
made of the injured shoulder, and thus giving the patient the 
benefit of an early diagnosis and early treatment of his sarcoma. 
Their failure to make this not difficult diagnosis resulted also in 
the ill-advised application of forceful mechanical measures, mas- 
sage, and manipulation to the shoulder, and has greatly in- 
creased the likelihood of regional and general dissemination of 
the sarcoma. 

This girl might have had, as the result of such a fall as pro- 
duced her initial injury, an impacted fracture of the external or 
internal tuberosity of the tibia, which is not at all uncommon, 
is often overlooked and then almost uniformly is treated as a 
sprain. These impacted fractures of the tuberosities of the tibia 
often lead to very serious situations for Uie patients as well as 




•1 



Fig. 358. — Chondromyxosarcoma of the 
upper end of the right tibia. This radiogram 
was made only a few days after the operation, 
while the limb was still in the plaster cast which 
was applied over the dressing at the time of 
operation. The upper wire nail is broken just 
below its head, an accident which very likely 
occurred in the operating-room during the dress- 
ing of the limb. The proper handling of the 
bone transplantation and arthroplasty cases 
during the application of the fixation dressing 
is a matter of the utmost importance, which 
can be intrusted only to thoroughly experienced 
and conscientious assistants. If the upper end 
of the transplant was fractured at the same time, 
which is not at all certain, it is not apparent in 
this radiogram. 

1 139 



Fig, 359, — Chondromyxosarcoma 
of the upper end of the right tibia. 
This radiogram was made a little more 
than five weeks after the operation. 
The cast had already been removed, 
and a line suggestive of a fracture 
through the upper end of the transplant 
is apparent. The entire transplant has 
already increased materially in thickness 
and its lower end has healed solidly 
in place by bony union. 




Fig. 360. — Chondromyxosarcoma of the upper end of the right tibia. Exci- 
sion of the right tumor and tibia over a distance of five and a half inches, leaving 
intact the upper articular surface of the tibia. Implantation into the defect of a 
bone-graft from the patient's left tibia. 

This radiogram was made on April 24, 19 14, two and a half years after the 
operation. There has, as yet, been no recurrence of the sarcoma either in loco or 
in distant structures. The transplant has grown into place and has increased 
materially in thickness. Its density is that of normal bone, and its alinement with 
the rest of the tibia is perfect. The phosphor-bronze wires used to fasten the soft 
parts about the bone transplant are still /;/ situ and have caused no trouble of any 
kind. The wire nail driven through the lower end of the graft to prevent the graft 
from l>eing forced too far down into the medullary cavity of the tibia is still in i)lace; 
and i>erfcctly solid lK>ny union has taken place here between the transplant and the 
tibial shaft. The nail which was used to fasten the upper end of the transplant 
to the upi)cr articular fragment of the tibia has broken in twain and the fragments 
of the nail lie widely apart. The same trauma which broke the nail may aLso have 
fractured the up|)er end of the transplant, or the fracture may have wcurred at a 
later time. This fracture subsequently failed to unite and resulted in a pscudar- 
throsis at this spot. Note that the extreme u|)i)er end of the transplant is firmly 
united by Ixjnc to the up|>er articular fragment of the tibia, showing that the l)one 
transplant healed successfully in place either before the unfortunate trauma ot - 
currcd which rcuultwl in the fracture, or after the accident had ha|)|H'ned. The 
femur and fibula show a slight "atrophy of disuse," but the tibia and the implant 
show normal or even slightly increased density. The small round shadow l\ ing 
lichind the outer condyle of the femur is the so-called Jabelta, a sesiimoid bone 
located in the outer head of the gastrocnemius and often mistaken by the uninitiated 
for a foreign body in the knee-joint— a very serious error. 

X140 




Fig. 361. — Same case. Antero- 
posterior radiogram made a few days 
after Fig. 360, and shortly before the 
second bone transplantation was per- 
formed. The pseudarthrosis at the 
upper end of the old transplant is now 
well marked and unmistakable. 



Fig, 362. — Same case. Lateral radiogram 
made a few days after F'ig. 360, and shortly 
before the second bone transplantation. 



1141 




Fig. 363. — Same case. Antero- 
posterior radiogram made seven weeks 
after the second transplantation of 
bone. Note the effective supix)rt which 
the second transplant gives to the inner 
tuberosity of the tibia in maintaining 
the normal level of the line of articula- 
tion at the knee. Note the many foci 
of bone absorption in the second trans- 
plant. As the regeneration of the bone 
gradually takes place from such osteo- 
blasts in the transplant as may survive, 
all these areas of resorption will be 
again filled out just as they were in the 
case of the first transplant. Regenera- 
tion does, in fact, appear to be already 
well under way at the ui)pcr end of the 
transplant, where the trabeculatcd 
structure of living bone is already quite 
definite, and seems to be progressing 
downward in a cone-shajjcd advance. 
Perhaps osteoblasts from the freshened 
under surface of the ui)iK'r tibial epiphy- 
sis have played a r6le in bringing alx>ut 
the regeneration of the up[>cr end of the 
transplant at an earlier dale than that 
of fh<- Ir.v*, r end. 

1 142 



Fig. 364. — Same case. 
Lateral radiogram made seven 
weeks after the second trans- 
plantation of bone. Note 
again the effective sup{X)rt 
which the second transplant 
gives to I he inner portion of the 
lower articular surface of the 
knee. .\n idea of how greatly 
the original transplant has 
grown in diameter can be ob- 
tained by noting what has 
hapi^ened to the deep wire 
sutures which originally en- 
tirely encircled the graft and 
now lie at least partly inside 
the bone or have been ruptured 
by its continued growth. 



SARCOMA OF THE RIGHT TIBIA II43 

the doctor. If the history had stated that this patient remained 
perfectly well for three months after her fall, and began to develop 
symptoms only after the lapse of a "free interval," one would 
have to assume that the process which later developed was not 
the direct result of the trauma, but the gradual development of 
a disease locaHzed at a locus minoris resistentice produced by the 
trauma; that, therefore, the primary injury produced not an 
impacted fracture or luxation of the joint, but merely a contusion. 
A joint contusion of mild degree is the type of trauma which is 
followed by tuberculosis and sarcoma. A severe trauma, such 
as produces a fracture or dislocation, practically never leads to 
tuberculosis or sarcoma. A severe trauma produces a marked 
tissue reaction, which is a direct protection against the local 
implantation of pathologic processes. 

The patient came to us for operation two and a half years ago, 
so that it is now five and a half years since the onset of her 
trouble, and four years since she had the cast applied and began 
to walk on crutches. The x-vsLy picture before the operation 
shows the tumor and the destruction of the bone. We made, 
with the help of the jc-ray, and confirmed by operation, the diag- 
nosis of sarcoma. The sarcoma had existed for at least two and 
one-half years before we operated. The parents said they would 
not consent to an amputation. They preferred the child's death 
to an amputation. We were willing enough that they should 
take that stand; therefore we decided to remove all of the neo- 
plasm and to make a transplant from the opposite tibia, retaining 
just the epiphyseal line and the outer portion of the head of the 
diseased tibia. We had to cut away the epiphyseal line right 
up to the joint surface over the inner tuberosity of the tibia. 
In the x-ray picture taken after the transplantation of the graft 
one sees that the epiphysis has continued to grow where it was 
preserved. Before making the bone graft we transplanted the 
fibula into the tibia by removing the cartilage and fastening the 
upper end of the fibula to the under surface of the head of the 
tibia to give the latter immediate solid support. The patient 
has developed a pseudo-arthrosis at the upper end of the free 
transplant, between it and the epiphysis of the tibia. That is 



1 144 CLINICS OF JOHN B. MURPHY 

what we have to remedy today. We shall transplant alongside 
the former graft another piece of bone from the left tibia. This 
added strength will give ample support to carry the patient's 
weight, and we have every reason to hope and believe that the 
sarcoma is finally eradicated, two and one-half years having 
elapsed since we excised the tumor. There has been no local 
recurrence of the growth and no development of metastases as 
yet. Therefore we believe that we have accompHshed in the 
way of permanent cure all that could have been accomplished by 
an amputation; and by this conservative course we have pre- 
served a useful limb. The patient is an only child — a daughter, 
sixteen years old now, and with her whole life ahead of her. Has 
not our course been well worth while if that life has been made 
useful and happy? 

There is another important lesson which this case teaches. 
The tiunor was demonstrable for at least two years preceding the 
operation, and its nature was recognized. If we could have said 
to the parents two years ago when they first refused amputation 
after finding that the rJCJ-ray showed a sarcoma, '*We shall, then, 
take out only the tumor and transplant a piece of bone in its 
place, " how much better the chances of permanently curing the 
patient would have been? During these two years of delay the 
sarcoma has been growing and has had continual opportunity 
to produce metastases. If we can save one patient by this 
operation two and a half years after recognizing the sarcoma, 
how many more could we save by taking out the growth the very 
minute the tumor is first seen. This growth was a chondromyxo- 
sarcoma. It is one of the more benign types of sarcoma, it is 
true; but in many of our earlier cases of this type we amputated 
the affected limb where we would not perform an amputation 
now but an excision. 

In carrying out our operation today we shall first open up the 
old operation site below the right knee and see how much of a 
transplant we need. We opened the right knee-joint at the 
previous operation and then closed it, as can be seen from the 
«-ray picture, which still shows the ^phosphor-bronze wire su- 
tures in sUu, 



SARCOMA OF THE RIGHT TIBIA II45 

[Dr. Murphy then made a longitudinal incision over the site 
of the scar of the previous operation and exposed the trans- 
plant.] 

The periosteum of the transplant closely resembles normal 
periosteum. If it did actually become necrotic after the trans- 
plantation, as some maintain, it has an apparently perfectly 
normal appearance now. We sutured the muscles back care- 
fully around the transplant at the operation two years ago, and 
they appear to have united firmly to it. (Continues the dissec- 
tion upward toward the joint.) The phosphor-bronze wire which 
we used to unite the muscles is now in my field, and I must cut 
and remove it to clear the field for the further procedures which 
we contemplate. The transplanted bone has increased in thick- 
ness to meet the requirements of the pressure of weight-bearing. 
We are now coming to the pseudo-arthrosis at the upper end of 
the transplant. The new joint has developed a splendid capsule 
— a fibrous capsule with osseous deposits rather than the normal 
capsule of a joint. Such is the case in most pseudo-arthroses. 
The fine of imion between the transplant and the shaft of the 
tibia is solid bone and firmly immobile. 

We must make a careful dissection to remove the excessive 
connective tissue which has formed between the broken ends of 
the transplant and the upper fragment of the tibia, and we must 
freshen the ends of the bone. We preserved the upper epiphysis 
of the tibia at the previous operation, and to it we shall attach 
the transplant which we shall make today, alongside this broken 
transplant which we made at the original operation. 

Let the record show that there is no evidence of a return of 
the sarcoma in loco. 

We are stripping up the periosteum on the old transplant 
because we wish to insert the new transplant under the periosteum 
of the old. This old transplant is firm and hard, just as the 
ic-ray picture shows it — not porotic anywhere. You can judge 
its density by the sound it produces when I strike it with the 
chisel. We have every reason to presume that it will unite 
firmly with the new transplant. The secret of success in all this 
bone work is to do it without hand contact with the wound. We 



1 146 CLINICS OF JOHN B. MURPHY 

are chiseling out a groove in the old transplant so as to produce a 
greater surface for the reproduction of bone, and also to hold 
the new graft more firmly in place. 

[Dr. Murphy covered the wound in the right leg with a sterile 
towel while he proceeded to cut a fresh transplant from the left 
tibial crest. The incision was longitudinal and to the inner side 
of the crest of the left tibia, following the scar made at the pre- 
\ious transplantation. The wound edges were spread with 
retractors, the bone exposed, and the regenerated periosteum 
incised, but not stripped, over the length and breadth of the 
proposed transplant. With the circular motor-saw a fragment 
of bone five inches long and about half an inch in diameter was 
excised. — Ed.] 

This is the same tibia and practically the same place where 
we took out the piece of bone at the previous operation. We are 
taking out this fragment of bone together with its periosteum. 
We are not convinced that the presence of the periosteum is 
necessary for successful bone transplantation, although Axhausen 
and others, especially Germans, maintain that it is. We have 
performed free transplantation of bone both with and without 
preserving its periosteum, and we have had uniformly good 
clinical results with both methods. We have had to remove 
only one transplant in over 100 cases where we have put them in. 
That removal we did just the other day. The man had a large 
hematoma after the operation. The hematoma became infected. 
We took out all the transplant because we feared it would merely 
act as a foreign body and delay the conquering of the infection. 
We took out part of another transplant on the same day, but 
left part in. So you see it never rains but it pours. That is, 
in brief, our experience with the free transplantation of bone. 
We have been transplanting the bone in all of our recent cases 
with its periosteum preserved. We shall not change from our 
plan so long as we continue to get good results. The main secret 
of success in this bone work, however, is to keep from getting the 
hands in contact with anything which touches the wound. We 
have made this statement many times already and shall repeat 
it many .times more, because of its overweening importance. 



SARCOMA OF THE RIGHT TIBIA II47 

[Dr. Murphy fastened the fresh transplant from the left 
tibia into position alongside the old transplant in the right tibia, 
beneath the periosteum of the latter and in the groove previously 
excavated for the reception of the new graft. — Ed.] 

We must take special care to get the new graft fixed in just 
the proper relationship to the other fragments. I wish to steady 
it at its attachment to the upper fragment of the tibia so as to get 
the mechanical support correct. All this bone work keeps one 
constantly on the alert. There are so many hands in the field 
of operation and so many things to do and to watch done that the 
conscientious operator is well-nigh swamped by the mass of 
details. 

Let the record show that we did not open the knee-joint at 
any stage of the procedures. 

Let the record show that we found a pseudo-arthrosis at the 
upper end of the old transplant; that we clipped away and 
chiseled out the capsule of this new joint; that we freshened its 
articular surfaces and approximated them so that they will 
unite; that we prepared one side of the former graft by denuding 
it of its periosteimi over a large extent of the surface so as to 
bury the new graft beneath the old periosteum, which we are 
leaving still attached at the borders to the old graft to stimulate 
it still further to the reproduction of bone; that the old graft 
resembled normal healthy bone in every particular. 

[Dr. Murphy resutured the leg muscles about the two trans- 
plants. Two naUs were driven through the new transplant to 
fasten it to the old transplant and hold it firmly in position. 
The upper end of the new graft was closely approximated to the 
freshly denuded surface of the upper tibial fragment and the 
muscles closely drawn about the two grafts to hold them securely 
in position. The skin was then sutured with silkworm-gut and 
horsehair. The wound in the left tibia was partly closed by 
drawing the adjacent muscle tissue across the raw surface of the 
bone; fascia and skin were reunited with silkworm-gut and horse- 
hair. The usual sterile dressings were applied to both wounds 
and a wire-gauze splint was used to immobilize the right leg and 
thigh.— Ed.] 



1 148 CLINICS OF JOHN B. MURPHY 

We have a very good muscle-flap here from the tibialis anticus 
with which to cover the defect in the left tibia and prevent the 
development of an adherent, painful scar. 

Let the record show that after exposing the pseudo-arthrosis 
we freshened the bone on the end of the former transplant and 
on the lower surface of the epiphyseal fragment of the tibia; that 
after the preparation of all these surfaces we took a fragment of 
bone about five inches in length from the opposite (left) tibia 
and transplanted it against the lower surface of the epiphyseal 
fragment of the tibia and alongside the former tibial transplant, 
carrying the attached periosteum with it. Let the record further 
show that we sutured the freed periosteum of the old graft over 
the new graft so as to cover in the latter's raw surfaces completely. 

This case looks like a very promising one for a splendid 
ultimate result because of the entire absence of any evidence of 
local or distant return of the growth. Will the new graft sur- 
vive? It will unless too many microorganisms have been ad- 
mitted with it. Some bacteria are always admitted into opera- 
tion wounds. Their subsequent role, however, depends on their 
number and virulence. If our graft does survive, will it unite at 
both ends — will it unite with the epiphysis and also with the 
former transplant? That it should unite to the former trans- 
plant is one of the things to be expected if the wound remains 
sterile. Will it unite to the upper tibial epiphysis? That is not 
so easy a question to answer. Why? In order to get a graft to 
unite it is essential to have superlative immobilization during 
the process of repair. It will be very difficult to obtain this 
superlative immobilization of the short upper tibial fragment, 
to which we were unable to fasten solidly the new transplant. 
We cannot drive in a nail here to hold the two fragments because 
it would almost inevitably enter the joint and make much trouble 
there. We merely let the transplant rest against the epiphysis. 
We are sure of the immobilization between the two grafts, but 
not of that between the new graft and the upper tibial fragment. 
If we obtain a generous reproduction of new bone from this 
transplant, we shall have made the patient's right tibia plenty 
strong enough to give her firm support. She could bear her 



SARCOMA OF THE RIGHT TIBIA II49 

whole weight on the right leg as it was; but it was too wobbly 
and uncertain for use without artificial support, because of the 
pseudo-arthrosis at the upper end of the old transplant. 

[Note. — A large hematoma formed in the wound after the 
operation. The blood was not aspirated until about the eighth 
day, and a culture of this blood showed the presence of staphy- 
lococci. Suppuration subsequently developed and the wound 
is still slightly open at its lower angle. The patient was im- 
mediately given an autogenous vaccine when the suppuration 
began, and it was relatively easily controlled. The bone graft 
has not come out. The patient is still in the hospital (September 
10, 1 9 14). — ^Ed.] 



EXOSTOSIS OF INTERARTICULAR SURFACE 
OF UPPER END OF LEFT TIBIA.— FRAC- 
TURE OF THE INTERNAL SEMILUNAR 
CARTILAGE 

HISTORY 

The patient, a bachelor aged forty-five years, with a negative 
past and family history, entered the hospital May 7, 19 14. He 
ascribes his present trouble to an old injury. Some twenty-four 
years ago — about 1890 — he accidentally ran the blade of a pen- 
knife into the inner side of his left knee, causing a great deal of 
pain during the following four days. The knee became puffed, 
especially on its inner side, the day following the injury, and the 
pain was much increased by bearing weight on the knee. The 
patient walked on crutches for six months following this injury; 
then for six months he walked with a cane. He was incapacitated 
for active physical work during all that year. The knee did not 
become red, that the patient remembers, and he does not recall 
having had any chills or fever. Since about 189 1 he has suffered 
no further inconvenience from the knee except for a feeling that 
it is not so strong as the right knee, and that it seems to bend 
backward somewhat at times. He has had no difficulty in walk- 
ing or climbing. 

About February 14, 19 14, the tendency of the knee suddenly 
to bend backward became more noticeable and more frequent, 
and there has often been a slight soreness in the joint at night. 
The patient can still walk without difficulty. He can fully ex- 
tend the knee and can flex it beyond a right angle. 

COMMENTS AND OPERATION 
Dr. Murphy (May 9, 1914): That the ancient injury re- 
lated in this patient's history is the actual cause of the exostosis 
seen in the rr-ray picture of his knee is difficult to say. If he were 

VOL. Ill — 72 1 151 



TI52 CLINICS OF JOHN B. MURPHY 

not positive that the knife-blade was taken out, I might think it 
was still there, so sharp and dense is that hard spicule of bone 
which projects upward from the spinous process of the tibia, 
apparently an exostosis starting from the surface where the 
knife-blade struck it. The trouble it causes him has been getting 
a httle worse of late. This bony tooth hes pretty well back in 
the joint. The examination of the a:-ray picture shows that 
access to this exostosis will not be easy. The point of bone is 
sticking up into the middle of his joint, however, like a needle, 
and must be removed to give the patient relief from his long- 
standing trouble. To get at this exostosis we shall have to open 
his joint more extensively than we should for the removal of a 
semilunar cartilage. 

[The Esmarch constrictor was appHed to the middle of the 
thigh. Dr. Murphy made a slightly curved rectangular incision 
over the inner side of the front of the knee close to the patellar 
ligament, which he did not, however, divide.] 

There is the fibrous capsule of the joint. I want to call your 
attention to the density of that capsule. See how firm and re- 
sistant it is! It acts like a leather bottle encasing the joint, 
holding in the products of infection and preventing them from 
escaping into the cellular tissue outside the joint. There is a 
space filled with areolar tissue between it and the articular 
synovial membrane. That is the terrain where the metastatic 
infections of the joint occur, between these two layers. Because 
of the density of the fibrous capsule the infection, if it spreads, 
cannot penetrate outward and, therefore, must break inward 
into the joint. 

[Dr. Murphy then divided the fibrous capsule and, together 
with it, the parietal synovium transversely, thus throwing the 
joint wide open.] 

In cutting this synovial membrane we endeavor never to pro- 
duce pressure on it. Pressure produces necrosis and necrosis 
leads to synechia?. [Dr. Murphy next carefully explored the 
joint.] There is an erosion on the edge of the patella, an erosion 
of the cartilage at its lower end. It looks like an area of arthritis 
sicca. Here is also a comminuted fracture of the internal semi- 




Fig- 365. — Exostosis of the inter- 
articular surface of the upper end of the 
left tibia. Anteroposterior radiogram. 
The tiiherculum inlercottdyloidemn mediale 
(B. X. A.) is prolonged upward into a 
sharp tooth which ap[)cars to impinge on 
the articular surface of the femur, or at 
least lies very close to it, just in front of 
the intercondyloid notch. The tiibcr- 
culum intercondyloidetim laterale (B. N. 
A.) is also somewhat more pointed than 
normal. The entire emincntia intercon- 
dyloidea (B. N. A.) (O. T. spinous process) 
is dintinctly more prominent than nor- 
mal. (We use the B. N. A. terms here 
because the old terminology had no 
names for these small structures with 
which we are dealing. — Ed.1 If the 
knife-blade was directly resjxjnsible for 
the production of this exostosis, it must, 
indeed, have penetrated nearly to the cen- 
ter of the joint — a very unusual injury. 



Fig. 366. — Exostosis of the inter- 
articular surface of the upper end of the 
left tibia. Lateral radiogram. The 
slight "lipping" of the corners of the 
patella and of the anterior margin of the 
tibia indicate the presence of a low grade 
of chronic arthritis which may be re- 
six)nsible for some of the sharpening and 
prolongation of the tubercula inlercon- 
dyloidea. 

It is reasonable to assume that in- 
fection following the knife-blade injury 
was the cause of this chronic arthritis. 
(The finding of other chronic arthritic 
changes in the joint at operation also 
lends strength to the vie^v that the chronic 
arthritis rather than the initial trauma 
was the chief causative factor in the pro- 
duction of the interarticular exostosis. — 
Ed.) 



"53 




ostosisof the intcrarLicular Fig. 368. I xo-iosis of the inlcrarticula 

surlace oi Llic ui>i>er end of the left tibia. surface of the left tibia. Lateral raili' - 

Anteroposterior radiogram after oi)eration. after operation. The normal conforn 

The normal conformation of the spinous of the spinous process of the tibia has ba 

process of the tibia has been restored. restored. 



1 54 



EXOSTOSIS OF UPPER END OF LEFT TIBIA II 55 

lunar cartilage. That is something we did not anticipate find- 
ing. It was, of course, invisible in the a:-ray plate, and the 
exostosis accounted perfectly for his symptoms. The fragments 
of cartilage must be removed. [Picks them out with the forceps 
and dissecting scissors.] Now we have a perfect view of the 
joint. That erosion on the articular surface of the femur where 
the exostosis has been scraping on it looks not unlike the erosion 
which develops in front of the excisor teeth with a pyorrhea. I 
think we have heretofore underestimated the significance of re- 
current traumas, even though shght, in the production of chronic 
joint changes. 

[Dr. Murphy exposed the central region of the joint by plac- 
ing the knee in semiflexion. The exostosis, an upward prolonga- 
tion of the tuherculum intercondyloideum mediate (B. N. A.), was 
readily brought into view, its base divided with the artist's chisel, 
and its synovial attachments freed, thus permitting its complete 
and easy removal. The synovial membrane was then sutured 
with fine catgut over the defect, after excising some of the ex- 
uberant fatty capsule. The Esmarch constrictor was removed, 
all hemorrhage stopped, the wound toilet completed, and the 
joint closed by accurate layer-to-layer approximation without 
drainage. — Ed.] 

The joint is closed with silkworm-gut and horsehair sutures, 
and we have now only the dressing to apply. We are incorpo- 
rating a Buck's extension in this dressing, as we do after every 
operation where we are compelled to open a weight-bearing 
joint. It prevents the subsequent development of synechiae. 

Let the record show that serious changes of a chronic ar- 
thritic character have occurred in the joint; that there was a 
fragmentation, especially marked at the margin, of the internal 
semilunar cartilage, apparently the result of an old fracture; that 
this semilunar cartilage was totally removed; that there was an 
erosion like that of an arthritis sicca at the margin of the under 
surface of the patella at its synovial attachment, extending back- 
ward one-fourth of an inch; that the same type of erosion was 
present on the side of the external and also of the internal con- 
dyle of the femur; that we exposed the middle of the joint by 



1 1 56 CLINICS OF JOHN B. MURPHY 

putting the knee in a position of semiflexion, so that we easily 
and readily brought the edge of the exostosis into view; that it 
was then chiseled free from its bony attachment; that the wound 
in the synovial membrane was accurately sutured with catgut 
after first removing some of the anterior fatty capsule; that when 
the constrictor was removed there was practically no bleeding, 
so that no ligatures were needed or applied; that the fibrous 
capsule was united with a separate row of catgut sutures and 
the skin closed with horsehair; that a Buck's extension was ap- 
plied to the leg and the knee dressed in a slightly flexed position, 
so as to put the muscles a little on the stretch. 

Whether or not this exostosis was the direct sequence of the 
knife sticking into the bone at that particular spot I cannot say. 
In cases like this one what a blessing the x-ray has been to us and 
to our patients! Without the knowledge obtained by it I 
should probably have taken out the internal semilunar cartilage 
only, and the patient would have continued to have trouble from 
this exostosis without our having any inkling as to the cause. 
Ordinarily, when we operate on a knee-joint with a history of re- 
current inflammatory attacks we inject the knee with formalin 
and glycerin a week before the operation, in order to produce a 
coffer-danmiing of the lymph-spaces in and outside of the synovial 
membrane by the mild inflammatory reaction which the formalin 
sets up. We did not adopt that procedure here, for the patient 
has had no recent infection of his knee-joint, although he has had 
recurrent inflammatory attacks several times in the more dis- 
tant past. The chronic vascular changes in his synovial mem- 
brane were very noticeable when we had the knee open, and they 
are sufl&cient to have produced thorough coffer-damming of the 
lymphatic spaces and have rendered our formalin and glycerin 
injection unnecessary; for such a thickened, vascular, synovial 
membrane is not nearly so liable to infection as is a normal sy- 
novial membrane. Speaking of the protective action of these 
chronic synovial changes brings to mind the fact that it took 
us a long time to learn that when a woman has a big abdominal 
tumor there is less danger of infection following its removal by 
laparotomy than when she has a small tumor, such as a little 



EXOSTOSIS OF UPPER END OF LEFT TIBIA 1 1 57 

ovarian cyst, for instance. The explanation of the apparent 
protection against infection of the peritoneiun in the case of 
large tumors follows the same lines. It is due to a coffer-dam- 
ming by the products and pressure of the tumor of the lymphatic 
spaces connected with the peritoneum. 

[Note. — The wound healed by complete primary union. 
The patient was allowed to get up on crutches during the fifth 
week after the operation. Motion in the knee was good, but 
slightly limited. He suffered no pain at any time, even when 
walking about. He left the hospital June 14, 1914, still on 
crutches and gradually gaining motion in the joint. No further 
report to date (September 10, 19 14). — ^Ed.] 



MULTIPLE METASTATIC ARTHRITIDES.— 
MULTIPLE ANKYLOSES.— ARTHROPLASTY 
FOR BONY ANKYLOSIS OF THE WRISTS 



HISTORY 

The patient, a married woman aged twenty-eight years, 
entered the hospital June 14, 19 10, with the following history: 
In April, 1906, she suffered quite a hard fall while skating, strik- 
ing on the spine. For a day or two following the fall she was quite 
sore through the back. In June, 1906, she developed a severe 
laryngitis and tonsillitis. There were patches of exudate present 
on her throat, resembling the patches of a diphtheria. This 
throat condition lasted for a week. She had fever and headache 
with it. The joints and back did not become sore. 

Since this attack the tonsils have remained sore and swollen 
until one and one-half months ago, when both tonsils were re- 
moved (about May i, 19 10). Since the operation there has been 
some soreness at the posterior part of the nasal passages. There 
is a slight nasal discharge usually present, which becomes more 
pronounced when the patient has a cold. At the time she had 
the tonsillitis, in 1906, abscesses developed around the back tooth 
of the lower jaw. The patient does not remember whether or 
not the dental abscesses bore any relation to her articular disease, 
although before each new joint involvement her throat trouble 
was more intense than usual. The alveolar sinus from the in- 
fected molar has continued to discharge pus until the present 
time. 

It was in the following December (1906) that she noticed the 
first trouble in the back of her neck. It began as a stiffness, 
which seemed to lie entirely in the muscles. At that time she 
could bend the head freely from side to side, but not so readily 
forward and backward. There was a dull pain constantly present 

"59 



Il6o CLINICS OF JOHN B. MURPHY 

in the neck for two years. Three weeks after the onset of the 
stiffness in the neck pain developed in the patient's right wrist 
and shoulder. So intense was the pain that it would not permit 
the least movement of the arm. The right wrist and shoulder- 
joints were very much swollen at the time, and the skin over 
them was dark red or purple in color. About this time the left 
wrist-joint also became involved. With the beginning of the 
involvement of each joint there would be slight fever. The first 
symptom of the onset of the trouble would be cramps in the 
muscles above and below the joint. In the muscles and joints 
there would then develop marked tenderness. The joints would 
swell to a size about one-third larger than their normal. . During 
the night she would be frequently awakened by the sudden pains 
caused by the involuntary muscular contractions. 

After the lapse of about six months the swellings gradually 
went down and the joints were left stiff. The left arm now shows 
more stiffness than the right. One month after the cessation of 
the active process in the elbows and wrist-joints she began 
having pain in the right hip. The pain became so sharp during 
walking that she had to stop and rest. At night, after retiring, 
she suffered from muscular contractions similar to those which 
she had had previously in the arms. They also caused sharp 
pains in the hip-joint. There was no fever noticed at this time 
or stiffness in the joint. She could wallv without difficulty except 
for the pain in the hip imtil, finally, her feet and ankles also 
became swollen and purple. The swelling of the feet extended to 
the joints of all the toes. She has been confined to bed ever since 
the feet became involved. The swelling and pain in the feet 
lasted four months, leaving the ankles stiff (bony ankylosis). 
The joints of the toes are not stiff. 

Since the patient became confined to bed, in 1907, she has re- 
mained there. But with her confinement to bed the progress of 
her trouble did not cease. She states that at that time a urine 
examination showed the presence of much uric acid. The right 
knee was the joint next involved, the first symptom being a feel- 
ing of weakness in it. This was three weeks after the involve- 
ment of the feet. There then developed swelling in the knee, 




I 




Fig. 369, — Complete bony ankylosis of the right wrist and carpus the result of a 
metastatic arthritis originating from an alveolar abscess. Roentgenograms made 
before operation. 



1161 




I*"ig. 370. — Arthroplasty for complete bony ankylosis of the riKhl wrisi and 
carpus. Note the good conformation of the new joint in spite of the shortening of 
the carpus, radius, and ulna, which resection prtnluced. Note that the joint inter- 
val of fully half an inch, which was produced by the resection, has already shrunk 
to normal width. In the lateral radiogram note the well-rounded contour of the 
ends of the forearm Ixjnes, esixjcially of the radius, and how well this contour fits 
Into the caqjus as a socket making a hinge-joint. Roentgenograms nuide seven 
weekf after operation. 

1 163 




Fig. 371. — Complete bony ankylosis of the left wrist and carpus the result of a 
metastatic arthritis originating from an alveolar abscess. Note that the lower end 
of the radius is completely fused with the carpus, while the lower end of the ulna 
shows bony ankylosis only at its outer angle. Anteroposterior roentgenogram 
made before oi)eration. 




Fig. 372. — Complete bony ankylosis of the left wrist and caqius, the result 
of a metastatic arthritis originating from an alveolar abscess. Lateral roentgeno- 
gram made before operation. 

1 163 





F'g- 373« — Arthroplasty for complete bony ankylosis of the left wrist. Note 
the good conformation of the new joint in spite of the shortening of the carpus. 
This shortening is a little less marked in the left wrist than in the right. Note that 
the hand has slid somewhat to the radial side, ai)parenlly owing to the fact that 
the end of the ulna, which was not involved in the bony ankylosis, was not resected 
far enough back from the joint and consequently tips the inner side of the carpus 
outward. 



1 164 



MULTIPLE METASTATIC ARTHRITIDES I165 

with muscular pains and a slight fever at the onset, lasting three 
or four days. The swelling of the knee did not go down for one 
year. The joint has remained stiff ever since then. At about 
this same time the left wrist also became involved. Three months 
later the left knee followed suit, and six months later it became 
stiff, although not absolutely fixed; for at the present time there 
is still a little motion possible in it. Six months later, in August, 
1907, both elbows became affected. They ran the usual course 
of symptoms, the right elbow being the worse. They can still 
be moved, but are painful. After the wrists were involved, the 
hands and fingers followed, becoming stiff also. Next came the 
mandibular joints. Movement of the mandible was very pain- 
ful during the acute stage of the arthritis, but it did not become 
ankylosed or suffer any eventual limitation of motion. The 
ankles became involved in March, 19 10. During the last year 
(1909) her throat has not given her any trouble. The ankles are 
swollen at the present time (Jvme 14, 1910), but not discolored. 
The joints involved during the last year have not shown so severe 
a type of the affection as those attacked during the early stages 
of the disease. 

The patient has actually gained in weight since the onset of 
her trouble. During the last year she has coughed a great deal 
mornings. She thinks the contuiual soreness in her nose is prob- 
ably the cause of the cough. Her appetite is good. Her bowels 
require laxatives to secure a daily movement. 

The patient left the hospital in August, 191 1, at which time 
she still could not walk. One month later, however, she became 
able to walk with the aid of crutches. In May, 191 2, she caught 
cold, developed slight fever, followed by swelling of the elbows, 
hands, and ankles. As the result of this fresh infection she was 
confined to bed from May, 191 2, to February, 19 13. She was 
imder phylacogen treatment during this time, 60 injections in all 
being given. During the last two months, March and April, 
191 2, she has been up and about on crutches. 

The patient returned to the hospital in May, 19 13. On May 
16, 1 9 13, her right elbow and left knee were bent under an anes- 
thetic in order to break up the fibrous adhesions present. On 



Il66 CLINICS or JOHN B. MURPHY 

May 28, 1 9 13, a knee arthroplasty by Dr. Murphy's pedicled 
fat-and-fascia-flap method was performed for the relief of a bony 
ankylosis of the left patella to the femur. The bony ankylosis 
was freed with the chisel, the patella was elevated, and the limb 
slowly and forcibly flexed to an angle of 45 degrees. A pedicled 
flap of aponeurosis and fat from the external surface of the thigh 
was freed and swung underneath the patella, between it and the 
femur, the tip of the flap sutured to the inner side of the femur. 
The fibrous capsule of the joint and the fascia were closed with 
running catgut sutures to take the tension off the skin sutures. 
The skin was closed with horsehair. 

On October 9, 19 13, the patient was again operated. An 
incision was made over the second joint of the index-finger of 
the left hand, the head of the phalanx removed, and a flail joint 
made. 

COMMENTS AND OPERATION 

Dr. Murphy (May 13, 1913): This is a very interesting 
case. We had here in the hospital at the same time with her 
three other cases that were all as much alike in their physical 
manifestations of disease as four peas out of the same pod, so 
common is this condition. I saw this patient originally in Texas. 
At that time she was in bed and had been in bed for something 
like five years, suffering with a chronic, recurring, multiple 
arthritis. After I visited her in Texas, she came up to Chicago 
for treatment. She had a bony ankylosis at that time of both 
wrists. She had complete fixation of both elbows. She had a 
solid bony ankylosis of both ankles, of one knee, and a fairly 
firm fixation of the other knee. There was limited motion in 
both of her hips. 

In looking for the focus of primary infection in this patient, 
what did we find? Exactly the same etiologic factor which we 
found in the three other patients who entered the hospital at 
about the same time. All these patients had suffered from 
chronic alveolar abscesses before the onset of their arthritides. 
Every one of them had deep suppurating sinuses running down 
to the roots of the teeth; and these sinuses had already existed 
over a period of years. 



MULTIPLE METASTATIC ARTHRITEDES I167 

This woman is a dentist's wife, so that we are able to get a 
fairly accurate history of the development of her condition. But 
her story is that again of the shoemaker's daughter who had no 
shoes — this patient's teeth had had practically no attention. 
There occurred, following the development of that sinus, a slow 
type of systemic infection, which is so frequent a sequel that it is 
rather characteristic of these alveolar infections. All four of 
these cases of systemic infection ultimately developed ankylosis 
of one or more large joints. 

We medical men, as a class, have been rather running away 
of late in the exuberance of ova expressions concerning the im- 
portance of the tonsil's reaction to these metastatic arthritides. 
The tonsil, it is true, is an important factor in their development, 
and, it seems to me, has a rather clean-cut relationship to the 
development of these inflammatory joint affections; but this 
relationship is more frequently seen in the acute arthritides than 
in the slow, recurring type. We are gradually learning now, 
from the observation of many cases, the underlying elements in- 
volved in these joint infections; and we believe that it will be 
but a short time imtil the problem of arthritis etiology is pretty 
well cleared up. The splendid work at present being done on 
the bacteriology of arthritis, especially by Rosenow at the 
Memorial Institute for Infectious Diseases, is bound to give us 
definite and clean-cut information on the etiologic factors back 
of these infections. To us every one of these multiple arthritides 
appears to be a systemic infection; and we have been teaching 
the metastatic origin of the multiple arthritides from a clinical 
standpoint for the last twelve years, and basing our therapy and 
management chiefly on this hypothesis. Now the bacteriologist 
is coming to the support of the position which we have taken in 
the matter, and which was based only on our knowledge of the 
clinical aspects of the cases, and on our patients' statements 
regarding events preceding the development of their arthritides. 

This woman wants, above all things, to obtain some motion 

in her wrist-joints. She has a bony ankylosis of both of them at 

present — an absolute fixation. My object to-day is to get one 

wrist free by performing a fat-and-fascia-flap arthroplasty. 

VOL. m — 73 



Il68 CLINICS OF JOHN B. MXHIPHY 

Look at that elbow! [Demonstrates the extent of motion in it.] 
We have succeeded in securing that range of motion by working 
at it continually and giving the patient vaccines. She now has a 
splendid elbow. We have also mobilized her hip- joints, so that 
after six years in bed she can now walk all over the house. Her 
hips were fixed by a fibrous, not a bony, ankylosis. 

The wrist is one of the joints where one would often like to 
make use of the Lexer plan of transplanting a free flap of fascia 
and fat from the trochanteric zone of the thigh to interpose 
between the articular surfaces. That would be the most desirable 
thing to do if we could be certain of its success; and it would 
also be the easiest thing to do. I should like to do it here, but 
** Conscience makes cowards of us all. " I do not dare to do it 
again, because the two cases in which I tried it on the knee both 
went on to a final fibrous ankylosis. Some of you may remember 
that in one of my articles I said that the free transplant of fascia 
and fat would be the ideal method of arthroplasty, simple and 
always available. Li the weight-bearing joints, however, it 
does not seem to me to be the proper thing. Li the wrist, which 
is not a weight-bearing joint, the method may work — at least, 
sometimes. Whether the transplant will stay in and live I do 
not know. Perhaps success by this method is only a matter of 
technic. Perhaps it is an impossibility. This much at least we 
do know. Free transplants of fascia and fat cannot be used in 
weight-bearing joints because they do not survive the pressure. 
They die and become transformed into connective tissue. 

My operative plan for this wrist is to make an internal and 
an external incision. Then slip an elevator in front and elevate 
all the soft structures in front of the joint; then, similarly, ele- 
vate all the structures behind. Next resect enough of the bone 
to make an interarticular interval wide enough to permit me to 
take a pedicled flap from the anterior margin of the ulnar side 
of the forearm above the joint, and swing that flap across the 
ends of the bones in the joint interval and bring it out on the radial 
side, and fasten it to the periosteum or ligaments on the radial 
side. Then I shall take a similar flap from the radial side of the 
joint and lap it over the ulnar flap. That is what I am going to 



MULTIPLE METASTATIC ARTHRITIDES 1 1 69 

try to do. The details of this arthroplasty work are so compli- 
cated and exacting that they put the operator under considerable 
mental tension; for nothing must be left undone that should be 
done, and nothing must be done that should not be. Above all, 
the hands and everything that has touched the hands must be 
kept out of the wound. 

[Dr. Murphy made a slightly curved longitudinal incision over 
the ulnar styloid process. He dissected down on the ulna and 
with the elevator began to separate the muscles, tendons, arteries, 
and ligaments from the anterior and posterior surfaces of the 
wrist-joint and from the bones forming the joint, taking particular 
care, however, not to dissect up the periostemn from the bones. 
See the accompanying series of drawings illustrating the steps 
of this operation. — Ed.] 

I am dissecting up the tendons, as you see, but I am leaving 
the periosteum on the bones. The ulna here looks as though 
it had been fractured at some time and callus thrown out. I am 
keeping above the periosteum while elevating the soft parts both 
in front and behind. Remember that in front it is much more 
difficult to get out the soft parts without the periosteum, because 
of the deep groove in which the soft parts lie. There is the line of 
imion of the ankylosis. Now, we have the soft parts fairly well 
freed in front. This dissection has gone better than I thought it 
would. Now we complete the freeing of the bone on the pos- 
terior surface, for everything has been freed in front. Now that 
both bones are freely exposed, we shall take off about one-half 
an inch of their distal ends to make sufficient room for our inter- 
posing flaps. 

[Dr. Murphy resected both bones with the artist's chisel, 
giving the ends a rounded contour to enable them to fit properly 
into the concavity of the carpus, which he likewise remodeled.] 

I am completing the new bony contours to my satisfaction. 
The resection of the distal ends of the ulna and radius enables 
us now to look clear through the wrist by way of this new joint 
cavity. This hole will be plugged subsequently by the pedicled 
flaps which I shall interpose. The width of it is about three- 
fourths of an inch. We can move the wrist, now that all the 



Iiyo CLINICS OF JOHN B. MURPHY 

bony obstructions have been removed, without the slightest 
tension on it in any direction. We always like these arthroplasty 
cases best when they have little excessive fat around the joint, 
as here. 

[Dr. Murphy begins to dissect up the pedicled ulnar flap 
from the outer anterior surface of the wrist.] 

There is going to be a lot of discussion in the near future as 
to whether this pedicled flap of fascia and fat lives or not after 
being turned into the joint, and whether it would not do just as 
well detached from its base. Let the surgeons who have little 
else to do discuss this subject. Whatever their decision as to the 
theory of it, we shall still continue the practice. Why? Be- 
cause, whatever others think to be the reason for our success 
with this method, we know it to be a success and, therefore, shall 
continue it without worrying about its theory. We cannot do 
otherwise. 

The superficial nerves of sensation will be disturbed here, of 
course, but that is a matter of small importance. If this fascial 
flap lives, there is no question about the patient securing a good 
joint. If it does not live, there is a considerable question about 
a serviceable joint being developed. 

[Dr. Murphy passes the pedicled ulnar flap over the ends of 
the two exposed forearm bones, and brings out its tip on the 
radial side of the joint, where he fastens it to the radial periosteum 
and to the fibrous tissue of the joint capsule.] 

That is the fibrous tissue of the joint capsule in front to which 
I am endeavoring to fix that tip. We got the flap just the proper 
length to cover over the ends of the bones nicely. We do not 
need continuous extension on the wrist- joint to prevent the flap 
from necrotizing, as we do in the case of weight-bearing joints, 
because the pressure of the bones on the wrist-flaps is never 
heavy enough to necrotize them. The places where one needs 
prolonged extension is where the muscles about the joint are so 
strong that their traction on the adjacent bones produces a 
pressure necrosis of the interposing flap. 

[The radial flap was prepared and interposed in like manner.] 

I do not know whether this case is going to give a good result 



MULTIPLE METASTATIC ARTHRITIDES II71 

or not. If it is not, it will not be treating me right, because I 
think that this is a beautiful apposition of flaps and bone which 
I have obtained. 

Let the record show that we first freed all the ligaments, 
tendons, arteries, and nerves from the posterior surface of the 
ulnar side of the joint; that after this had been accomplished 
on the ulnar side, we went in on the radial side of the joint and 
carried out the same procedure, so that both openings met; that 
we endeavored to leave the periosteum on the portions of bone 
removed so as to lessen the likelihood of exostosis development 
after the operation,' and to lessen the Hkelihood of a reunion of 
the freshened bony surfaces; that when that was fully accom- 
plished, we excised between one-half and five-eighths of an inch 
of the lower ends of both ulna and radius clear across the entire 
width of the joint, leaving a convex surface on the lower end of 
the radius and ulna and a concave surface on the carpal side; 
that when this new articular interval was perfectly free, so that 
one could see clear through the space, and when all the tissues 
in front and behind the bones were freed from the latter, we 
prepared an interposing pedicled flap of fascia and fat from the 
ulnar side of the joint and the anterior margin of the forearm and 
put it in between the ends of the bone; the flap contained a 
large quantity of fat, besides fairly well-organized fascia, leaving 
nothing but derma on the skin-flap, since we needed all the sub- 
cutaneous tissue to interpose in the joint; that the fascial flap 
was pedicled downward, the base of the pedicle lying slightly 
above the level of the new joint. 

It does not matter from which direction the flap is detached, 
so extensive is the collateral circulation in the wrist, as is shown 
nicely in the x-vay photographs of wrist- joint preparations with 
the blood-vessels containing metallic injection masses. (Dr. 
Hochrein.) 

Let the record show that we prepared a second interposing 
flap from the posterior radial side of the joint, an inch in width, 
and containing a large quantity of fat and well-organized fascia, 
leaving nothing but derma in the remaining portion of the radial 
skin-flap, just as on the uhiar side; that we applied no extension 



II72 CLINICS or JOHN B. MURPHY 

to the joint; that a wire-gauze splint will be applied extending 
from the fingers up to the shoulder; that the arm will be dressed 
in slight anterior flexion and will be held in an elevated position. 

We neutralize all the surplus iodin, because the patient is a 
blonde. Such persons are thin-skinned and blister easily. What 
we particularly tried to do here was to preserve a slight convexity 
on the lower end of the radius. The new joint does not need to 
slide, only to bend. In the elbow one needs a sliding- joint, and 
in the knee also; but not in the wrist. 

We finally have secured a mixed vaccine which gives the 
patient a marked reaction. It is a mixture of gonococcus, 
streptococcus, and staphylococcus strains. She develops a 
temperature and she feels sick after its injection. When these 
patients get a marked reaction from their vaccine, one is quite 
sure that they will be benefited by it. If they get no reaction, 
one might as well give them so much water, so far as any real 
benefit to them is concerned. This was one of the early cases of 
the sort that came to us, and we have nm the gamut of our 
therapeutic resources with her. We are not certain to which 
particular remedy to attribute the favorable results. One could 
not help being impressed with having the four cases of the same 
kind in the hospital at once — all with the same alveolar infection 
and the same multiple joint involvements. The similarity of the 
ankyloses and the way in which they occurred were so striking 
that one could not get away from the impression that the arthri- 
tides bore a definite relation to the infections in the alveolar 
processes. Once these germs get into the system, they seem to 
act very much like the spirochetes of Schaudinn; they may lie 
dormant for years. Then some change occurs in their cycle or 
some alteration in their host's resistance, and off they start again, 
just exactly as we know the syphilis spirochetes do, first lying 
dormant for years and then breaking out into sudden, and often 
violent, activity. Why we see this same treacherous course in 
this type of arthritis we do not know; but the clinical observa- 
tion is well established that we do. 



MULTIPLE METASTATIC ARTHRITIDES 1 1 73 

Arthroplasty of Left Wrist 

[Intern reads history.] 

Dr. Murphy (July 2, 1914) : There are two important points 
which the doctor wishes to bring out in that history, but they are 
lost in the delivery. One point is that the patient had an alveolar 
abscess draining into her mouth for a number of years; the second 
is that she had also a recurrent tonsUlitis with a chronic pharyn- 
gitis. The chronic inflammation of the mucous membrane 
involved not only the pharynx, but extended also to the posterior 
nares. Whether it began above in the nose or below in the 
pharynx, we could not determine. We are much incKned to 
believe that this infection of the joints came from the alveolar 
abscess. After she had developed these multiple arthritides, 
she came here to the hospital in a very bad condition. Many of 
the joints were already ankylosed — some of them partially and 
some of them completely, some fibrous and some bony. Both 
hips and both elbows were firmly fixed by fibrous adhesions. 
Both wrists and both ankles were in bony ankylosis. One knee 
had a bony ankylosis and one a fibrous fixation. 

We performed an arthroplasty operation on one knee, but did 
not obtain satisfactory motion. We secured a movable patella 
and a movable joint, but the degree of motion is not satisfactory. 
When the patient entered the hospital she would not tolerate the 
additional pain which was the necessary accompaniment of the 
increase of the range of motion even in the hope of relief, although 
she suffered severely and frequently with the pain of her arthri- 
tides. We could not get her to allow us to make passive motion 
in her knee after the arthroplasty imtil it was too late to ward off 
great limitation of motion; and, nevertheless, there is no return 
of the bony union in the knee: there is only a fibrous Kmitation. 

We shall put the various joints through passive motion again 
to-day, after the patient has been anesthetized. She had been 
in bed for six years continuously at the time we started to limber 
up her joints. Now she is able to spread her limbs well apart, 
and she walks without cane or crutch. She can walk arornid 
the house very well. We have already operated on the bony 



1 1 74 CLINICS OF JOHN B. MURPHY 

ankylosis in one wrist. We are going to operate on the other 
to-day. We are going to put her partly mobilized joints through 
passive motion while she is still under the anesthetic, after the 
wrist operation. Muscular relaxation will be complete by that 
time, and it will be easier then to break up the fibrous adhesions 
than at the beginning of anesthesia. 

This other knee arthroplasty was done in the early period of 
our arthroplasty work. We did not take off, in my opinion, a 
sufl5cient amount of the joint capsule. We resected enough of 
the bone, however, and got a splendid conformation to the knee. 
It looks exactly like a normal knee. In the other knee we im- 
planted a pedicled fascia-and-fat-flap after separating the bony 
ankylosis between the patella and the femur; but the motion 
in this knee also is not satisfactory, notwithstanding the fact that 
she is able to walk with it. 

[Intern applies the Esmarch constrictor to the patient's arm.] 

I intend to remove the constrictor just as soon as the bone 
resection is completed, so as to get all the bleeding stopped be- 
fore we close the wound. Thorough hemostasis is very necessary 
in these arthroplasty wounds, because the formation of a hema- 
toma interferes materially with healing. The patient has ob- 
tained an excellent degree of motion in the right wrist, on which 
we operated about two months ago. She has fairly good motion 
in her elbows. The elbows were both fixed with a fibrous anky- 
losis when the patient entered the hospital. By injecting for- 
malin and glycerin into these two joints, and, later, using passive 
motion, we succeeded in loosening them up. These elbows are 
now both very satisfactory in the degree of motion obtained. 

Visiting Doctor: What vaccines did you use on this patient? 

Dr. Murphy: We used both autogenous and stock vaccines, 
and also phylacogens; in fact, everything we could think of in a 
therapeutic way. We had no real guide as to the specific micro- 
organism causing the infection, but the patient gave a strong 
reaction to our fresh, mixed vaccine, and wherever there is a 
strong reaction, there is, usually, a good therapeutic result. 

[Dr. Murphy then performed the wrist arthroplasty (left), 
using a single pedicled flap of fascia and fat obtained from the 





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MULTIPLE METASTATIC ARTHRITIDES I181 

dorsal surface on the radial side of the wrist, instead of the two 
pedicled flaps which he used in the operation on the right wrist.] 

Let the record show that there was a complete bony ankylosis 
of the carpal bones to the ulna and radius; that the lower ends 
of the ulna and radius were resected for about five-eighths or 
three-fourths of an inch, in order to make a new articular interval; 
that the exposure thus made of the new joint was excellent, in 
spite of the fact that only a single incision was made for the 
purpose — a radial incision; that the division of the ankylosis 
was semicircular, the concavity of the semicircle lying upward 
and the convexity downward; that we then prepared a flap from 
the dorsum of the radial side of the forearm and interposed it 
between the two forearm bones and the carpus for the entire width 
of the wrist, passing the tip of the flap through the joint with a 
Reverdin needle, and fastening it to the joint capsule on the ulnar 
side, so that the flap was fully fixed in position over the entire 
width of the joint cavity; that an ectropion suture of the skin 
wound was made in closing, in order to throw the skin-edges out 
and keep them from becoming fixed to the extensor tendon of 
the thumb. We shall dress the wrist in a perfectly straight 
position. 

Before allowing the patient to come out of the anesthetic, 
we shall put both her knees through passive motion. This left 
knee was in bony ankylosis. With the very slightest motion we 
are able to loosen the patella and move it a little from side to side. 
She has no ankylosis of the knee now. 

[Puts the knee through a gradually increasing range of flexion 
and extension.] 

Passive motion in the knee must always be carried out by 
gradual working of the knee to and fro imtil the desired range of 
motion is obtained. If one attempts to produce maximum 
flexion at once, one is likely to snap the patellar tendon. Passive 
motion must not be carried to the point of producing a hemor- 
rhage into the joint. If a hemarthros is produced, a much 
greater degree of stiffness will develop after the passive motion 
than was present before. I can feel this fibrous tissue in thai 
joint slowly give. Now we can demonstrate the mobility of the 



Il82 CLINICS OF JOHN B. MURPHY 

patella to be distinctly greater than it was before our manipula- 
tions. The reason why the range of motion in this knee is still 
somewhat limited is because the patient was so imwilling to stand 
the not very severe pain that is involved in the periodic manipula- 
tions necessary to preserve the range of motion gained by the 
arthroplasty. One can readily see from the increased mobility 
of the patella that this passive motion will be of great value to 
her if we can induce her to allow us to keep it up. 

One has to be careful in handling the patient's hip- joints dur- 
ing passive motion, because there is some fixation present, and 
there is no bone which breaks so readily imder the surgeon's 
manipulations as the femur. The right patella is just as movable 
as a normal knee-cap, but there is not so much motion in the knee 
joint itself, for the same reason that the patient did not obtain 
a wider range of motion in the left knee — she could not bear even 
shght pain, although the motion in her knees and her ability to 
walk were at stake. There is practically no tension on the patella 
on the right side. Most of the fixation and tension are in the 
ligaments. 

I am also loosening up all these other joints which are not 
ankylosed by bone. They need merely some stretching of the 
fibrous tissue. The patient will be a bit sore in these joints to- 
morrow. I think we shall have to elongate her tendo Achillis 
to obtain the proper result in this ankle. 

In dressing the wrist which we have just operated we shall 
put on a straight splint of wire-gauze, which comes around on 
both sides of the wrist. This is the new (right) wrist. The 
arthroplasty was performed about five weeks ago. See what a 
perfect result it is going to be! The same technic was followed 
in the right as in the left wrist to-day, except that in the left 
wrist we made the opening into the new joint only from one side 
(the radial). There was a little dry necrosis of the skin at one 
spot on the right wrist following the operation, but not enough 
to be of any consequence. I hope that we secure as good a 
result with the left wrist arthroplasty as we did with the right. 

[Note. — ^The patient is still in the hospital (September i8, 
1914). The result on the right wrist is splendid, the conforma- 



MULTIPLE METASTATIC ARTHRITIDES 1 1 83 

tion almost normal, and the motion good. The left wrist has 
luxated slightly to the radial side without any apparent cause 
being present except the relatively rather long ulna which tends 
to rotate the carpus outward. Her general condition remains 
about the same or a little improved, in spite of the remonstrance 
which she makes to passive motion. — Ed.] 



VOL. m — 74 



CARTILAGINOUS EXOSTOSIS OF LEFT HUM- 
ERUS.— EXCISION 



HISTORY 

The patient, a boy aged thirteen years, entered the hospital 
with the following history: 

About six weeks ago, March 15, 1914, he noticed a tumor on 
the upper part of his left humerus, about midway between the 
lateral and posterior aspect of the bone and approximately two 
or three inches below the shoulder. He saw a doctor who said 
x-iay pictures should be taken frequently to watch for any notice- 
able growth of the tumor. Accordingly, an a:-ray picture has 
been taken every week since the tumor was first noticed, and, 
therefore, it can be definitely stated that the tumor has grown 
half of its present size since the first picture was made. The 
patient's doctor said that the tumor was spur-shaped. The 
patient can recall no injury to the arm, except that four years 
ago he struck one arm with a board and the arm was carried in a 
sling for two days. He does not remember, however, which arm 
it was which was injured. He has had no chills or fever since the 
tumor appeared. The growth is now about the size of a walnut, 
hard, not painful and not movable, but firmly fixed to the bone. 
There is no tenderness present. The arm can be moved freely 
in all directions. 

COMMENTS AND OPERATION 
Dr. Murphy (May 2, 1914): On what date was the first 
picture made? 

Intern: About the middle of March, 19 14. 
Dr. Murphy: What was the date of the injury? 
Intern: Four years ago. 
Dr. Murphy: What was the injury? 

1185 



Il86 CLINICS OF JOHN B. MURPHY 

Intern: He struck one of his arms with a board, but he does 
not remember which arm it was. 

Dr. Murphy: Following the traiuna, he has no recollection 
of any significant symptoms remaining. This tumor lies just 
outside the insertion of the left deltoid muscle. The musculo- 
spiral nerve curves aroimd the himierus just below the tmnor. 
The growth is in a position where it is accessible without hazard- 
ing any of the large nerve-trunks in the operation. 

[Dr. Murphy made an external longitudinal incision over the 
margin, not the center, of the tumor. The growth was then ex- 
posed by blunt dissection and removed with the chisel and ham- 
mer. The anterior branch of the musculospiral nerve lay on the 
inner side of the tumor. Dr. Murphy then demonstrated the 
specimen to the visiting surgeons.] 

This bony tumor is covered with a cartilaginous cap. Its 
location at the upper end of the humeral diaphysis, its hook shape, 
and, above all, its cap of cartilage over a matrix of bone, enable 
us, even without a microscopic examination, to make a positive 
diagnosis of a cartilaginous exostosis, first so named by Cooper 
and later called " ecchondrosis ossificans" by Virchow. We 
cannot show you a microscopic specimen of this tumor to-day, but 
shall do so as soon as the pathologist has decalcified the tumor and 
cut it. The apparently rapid growth of the tumor in this boy is 
not to be interpreted as the expression of a possible malignancy, 
as the boy's doctor apparently thought. These cartilaginous 
exostoses grow most rapidly about the time of puberty, and are, 
therefore, first noticed by the patient, as a rule, about this time. 
They very rarely undergo malignant degeneration. 

We used to think that many of these cartilaginous exostoses 
were of traumatic origin, the bony organization of a subperiosteal 
hematoma, for instance. Of course, such a protruding tumor is 
very liable to mechanical insults. Since, however, our attention 
has been called by Pels-Leusden, Drescher, R. T. Vaughan, and 
others, to the great frequency with which these tumors affect 
many of the long bones in the same individual, and several in- 
dividuals in the same family, and, also, that these tumors are 
sometimes demonstrable at birth in "exostosis families," we are 



CARTILAGINOUS EXOSTOSIS OF LEFT HUMERUS I187 

coming more and more to regard cartilaginous exostoses as a 
hereditary skeletal disease, as yet unknown in its etiology, but 
perhaps ultimately dependent on some intra-uterine disturbance 
of the interrelationship of the glands of internal secretion con- 
trolling skeletal growth. 

[Note. — ^The wound healed by complete primary union. He 
left the hospital on May 7, 1914, without the motion in his arm 
being interfered with in any way by the operation. — Ed.] 



BILATERAL TUBERCULOUS EPIDIDYMITIS 
WITH ABSCESS FORMATION.— RESECTION 
OF EPIDIDYMIS AND VAS ON BOTH SIDES, 
LEAVING THE TESTES 



HISTORY 

The patient, a married man aged thirty-three years, entered 
the hospital with the following history: Neither he nor the mem- 
bers of his family have shown any evidence of tuberculous infec- 
tion until the onset of his present trouble, in August, 1913. He 
was loading a wagon when he slipped and fell astride of the side 
board, striking with his full weight on the perineum. At the same 
time he struck the comer of the seat with his left loin. He did 
not have any pain in the testicles following the injiuy, but he 
went to bed at once, because of pain in his back. One day later 
he noticed that his left testicle was swollen as large as his fist 
and had become very tender and painful. This testicular pain 
lasted for one month and then subsided; and the swelling di- 
minished about half. About one and one-haK months after the 
injury the right testicle gradually became swollen to twice its 
normal size, but did not become tender. The size of the testicles 
did not incapacitate him for walking. He does not know how 
long the testicles remained swollen. He has had no chills or fever 
to his knowledge, and he never has had any difficulty with 
urination. He has never had any shooting pains in the abdomen. 
He feels otherwise in perfect health. The left testicle at present 
is larger than the right, and is about 50 per cent, larger than 
normal. The right testicle is about the normal size. The epididymis 
in both testicles is enlarged, nodular, and very hard and tender. 

COMMENTS AND OPERATION 

Dr. Murphy (April 25, 1914): What is the matter with 
him? 

1189 



IIQO CLINICS OF JOHN B. MimPHY 

Intern: He probably has a tuberculosis of the epididymis. 

Dr. Murphy: What makes you think so? Because the diag- 
nosis is on the blackboard? 

Intern: Because both epididymes became hard and nodular 
following an injury. 

Dr. Murphy: Why might it not be a malignancy? 

Intern: Sarcoma does not usually begin in the epididymis. 

Dr. Murphy: How do you know it began in the epididymis? 
You have no right to assume that it did imless you know positively 
that it did. He says it began in the testicle. What is the matter 
with him, and why? 

Intern: The only thing I can think of which it could be is a 
tuberculosis. 

Dr. Murphy: Why might it not be a syphilis just as well as 
a tuberculosis? Why not a Neisserian infection? 

Intern: He denies venereal infection. 

Dr. Murphy: Yes, but lots of men deny venereal infection 
who have a Neisserian epididymitis. What is there in the history 
to show what it is? 

Intern: The process traveled from the left testicle to the 
right. 

Dr. Murphy: That occurs, too, with a Neisserian infection. 

Intern: I do not think of anything else. 

Dr. Murphy: What are the symptoms of tuberculosis of the 
epididymis? 

Intern: A history of injury. 

Dr. Murphy: Yes, trauma. Next, what? What is usually 
the first symptom of a tuberculosis of the epididymis? 

Intern: Pain. 

Dr. Murphy: Pain where? 

Intern: In the testicle. 

Dr. Murphy: Yes. What is generally the second symptom? 

Intern: Swelling. 

Dr. Murphy: Yes. What is the third symptom? 

Intern: Hardness. 

Dr. Murphy: Not at all. I should put frequent urination 
next. Often the first symptom that attracts the patient's attention 



BILATERAL TUBERCULOUS EPIDIDYMITIS IIQI 

is the increased frequency of urination. It is not the primary 
symptom of the disease so commonly as it is in tuberculosis of 
the kidney. With tuberculosis of the kidney the increased fre- 
quency of urination is the most common primary symptom, but 
it is also an early symptom of tuberculosis of the epididymis. 
All right, doctor, what else? 

Intern: That is all. 

Dr. Murphy: No. Sarcoma, too, often occurs simultaneously 
in both testicles. Sarcoma occurs also in both ovaries, and more 
commonly than it does in both testicles. Bilateral sarcoma is still 
more frequent in both kidneys. When it begins in one kidney 
and is removed, it practically always recurs in the other kidney. 
There are only a few cases on record of true sarcoma of the kidney 
that have been permanently cured by radical operation, because 
the recurrence nearly always takes place in the other kidney. 
In this clinic we have had a great number of sarcomas involving 
the ovaries and the testicles, as well as the kidneys. They occur 
in just about that order of frequency: A double sarcoma of the 
testicle not frequent; a double sarcoma in the ovary frequent; 
a double sarcoma in the kidney almost always, either sooner or 
later. 

We have here on the board a chart showing the relative fre- 
quency with which different parts of the testis and epididymis 
are involved in the tuberculous process. (See Clinics for 
February, 19 14, page 67.) The place most commonly involved 
is the mucosa of the epididymis at the globus minor. This involve- 
ment includes both primary and secondary lesions. The next 
location in point of frequency is the body of the epididymis, next 
the globus major, then comes the hilum of the testicle, and rarely 
the body of the testicle. We have never seen a primary tubercu- 
losis in the testicle in all our experience. Occasionally the true 
testicle is involved secondarily, for a tuberculous abscess may 
burrow from the epididymis into the testicle proper, destroying 
the tunica albuginea en route. 

This patient first had a tuberculosis in one side of the scrotum 
and then in the other. We aspirated some of the pus from the 
abscess, which is here, but found no tubercle bacilli — just a cheesy 



II92 



CLINICS OF JOHN B. MURPHY 



material. Notwithstanding that fact we are convinced that what 
we have to deal with here is a tuberculosis of both epididymes. 
In operating these cases we follow a definite and conservative 
plan. We practically never remove the entire testicle. There 
is no more occasion for taking out the whole testicle for tuber- 
culosis of the epididymis than there is for taking out the caput 



SpermsTic 
srt: 



Arteries "to , 
epiaidym/s 




Fig. 380. — Arterial supply of the testicle and epididymis. The spennatic 
artery sends off the branches to the epididymis at some little distance above the 
epididymis. In excising the epididymis the arterial supply to the testicle is in no 
way compromised (after Testut). 



coli in an appendicitis. The testis can be retained and its vascular 
supply retained. As soon as we make a diagnosis of a tuberculosis 
of the epididymis we advise its immediate removal. The very 
day of the diagnosis, remove the epididymis. Once tuberculosis 
develops in it, it never again becomes a carrier of semen, so there 
is no reason for keeping it. 



BILATERAL TUBERCULOUS EPIDIDYMITIS II93 

[Dr. Murphy makes the usual low inguinal incision, first on the 
right side.] 

This is the testis in which the abscess was located. There 
appears to be a serous accumulation in the tunica vaginalis at the 
point where we went in. This effusion in the tunica vaginaKs is 
identical with the serous effusion which often takes place in the 
pleura in tuberculosis of the lung. The globus major, as you see, 
is independent of the main tuberculous mass. When a tuber- 
culous abscess ruptures from its position of origin in the epididymis 
through the tunica albuginea, if there is a severe mixed infection 
present, destruction of the testicle may ensue. By doing this 
conservative operation we preserve the secreting portion of the 
testicle, and thus save to the patient the internal secretion of the 
testes, although the external secretion — the semen — is lost. The 
patient consents to this type of operation early in the course of 
the disease — particularly so when both testicles are involved. He 
does not consent so easily to a removal of the testicle. 

[After the epididymis was dissected free from the right testis 
the vas was pulled down as far as possible and removed with the 
epididymis. The mucosa in the stimip of the vas was cauterized 
with carbolic acid (95 per cent.) as high up as the carrier could 
be inserted, which was about three-fourths of an inch. The stump 
was then ligated. The object of the cauterization was to destroy 
any tubercle bacilli lurking in the mucosa, and thus prevent the 
subsequent development of a scrotal fistula. After closure of the 
woimd on the right side the same operation was performed on the 
left testicle and epididymis. — Ed.] 

There is a hydrops also present in the left tunica vaginalis. 
Dissecting away the epididymis from the testicle is not a difficult 
task at all, but should be done carefully with due regard to preser- 
vation of the blood-supply of the testicle. The vas is not a patent 
conducting tube in such a case, but that fact does not matter to 
the patient. He does not know it and he does not care. But he 
does care about preserving his testicles — not that he knows their 
value as organs with an important internal secretion, as we do, 
but because he attaches a sentimental value to them. One rarely 
ever finds tubercle bacilli in this serous fluid in the timica vaginalis. 



1 194 CLINICS OF JOHN B. MURPHY 

One rarely ever finds tuberculosis on the surface of the tunica 
albuginea, but finds it very frequently present on the surface of 
the epididymis. The abscess in this epididymis is threatening to 
break through the wall of the epididymis into the tunica vaginalis? 
just as a tuberculous focus in the lung breaks through into the 
pleura or as a focus in the end of a long bone breaks through into 
the neighboring joint, or as a Fallopian tube full of cheesy debris 
discharges its contents into the peritoneal cavity. Occasionally 
these tuberculous abscesses not only rupture into the timica 
vaginalis, but also go right through the tunica albuginea into the 
testis. In children, when they do pursue this course, the result is 
fatal to the testicle. In adults, however, one can save the testicle. 

In dosing the woimd every single vessel must be tied to avoid 
the formation of a hematoma. We also put in a little gutta- 
percha drain, which will remain for from twenty-four to forty-eight 
hours. 

This patient has had no vesical irritation, in spite of his ad- 
vanced genital tuberculosis. It is rare with cases so far advanced 
in the disease as this patient is to enjoy this complete freedom 
from dysuria. Not only have they often pus in the urine, but 
many times blood as well. I recall one of my earlier experiences 
with a case of this kind, when I was at the Presbyterian Hospital, 
twenty-seven years ago. I had imder my care there a man with 
tuberculosis of the right epididymis. He was a missionary, and 
his frequency of urination was so great that he n ver could hold 
his urine beyond twenty minutes at a time, and, therefore, he 
was out of commission for his life's work. He could not deliver a 
speech or a sermon more than twenty minutes in duration. The 
demands of his bladder were too insistent. Nor was his curse the 
parish's blessing, for he was an eloquent and gifted man. Finally 
he developed several profuse hemorrhages. One might have 
thought that these hemorrhages were due to a beginning tuber- 
culous ulceration of the bladder, but that evidently was not the 
case at all, for we just took out the epididymis, treated the end 
of the vas exactly as we did here — with 95 per cent, carbolic 
and ligation, and the frequency of urination and hemor- 
rhage entirely disappeared. We have had a number of similar 



BILATERAL TUBERCULOUS EPIDIDYMITIS 1 1 95 

cases since then, and the hemorrhage usually ceases promptly 
after the removal of the epididymis, as it would not do were the 
hemorrhage due to tuberculous ulceration of a mucous membrane. 
He never developed the disease in the other testicle. He weighs 
287 pounds now, and it is already twenty-seven years since the 
operation. That shows how perfectly well these cases may be- 
come, and how perfectly well they may remain permanently. 
The hemorrhage is from the swollen vessels of the neck of the 
bladder, which dilate when the prostate or the seminal vesicles 
become enlarged or inflamed. 

Let the record show that both epididymes were involved by 
the tuberculosis; that on the right side there was a peri-epididymal 
abscess; that abscesses were opened in both testicles; that the 
entire field was sponged out several times with 5 per cent, carbolic, 
and a gutta-percha drain inserted in closing the wound. 

[Note. — Following the operation a hematoma developed and 
a saprophytic infection followed, which drained about a month 
before closing. Otherwise the patient made an uneventful re- 
covery, — Ed.] 



GUMMATOUS TUMOR OF THE TESTICLE 



fflSTORY 

The patient, a married man aged forty-two years, entered the 
hospital with the following history: His mother died of tubercu- 
losis at the age of forty-five. His mother's father, five sisters, and 
one brother died of the same disease. His father is living, at the 
age of sixty-eight, but has a heart lesion with anasarca. He has 
two sisters and one brother living and well. One brother died in 
infancy of abscess of the liver. The patient denies venereal in- 
fection. He has never been seriously ill before now, he says. 

His present trouble began on May 15, 191 3. While lying on 
his back in bed reading, his little six-year-old daughter dropped 
a book, a comer of which in falling struck his left testicle, 
which was protected only by his sleeping gown. The little girl 
was standing erect when the book was dropped, so that the book 
fell a distance of about two feet. The injury immediately produced 
severe pain and nausea, which lasted from fifteen to twenty minutes. 
No remedies were applied, for the pain gradually subsided, and 
the patient rested well that night. He felt no pain the next morn- 
ing, but the testicle was slightly swollen. This swelling gradually 
increased, and the pain returned and increased in proportion to 
the swelling. At the end of five or six days the testicle was about 
five times its normal size, and the patient was incapacitated for 
walking on accoimt both of the pain and of the large size of the 
swelling. The pain was heavy, dragging, and pulling in character, 
and was relieved by lying on the back. 

This pain and swelling remained practically the same for a 
period of two weeks, and then began to subside; but the testicle 
has never reached its normal size since then, although it did 
finally become reduced to about twice its normal size and re- 
mained so for a period, of about ten months, except when the 

1 197 



IIqS clinics of JOHN B. MURPHY 

patient was long on his feet or walked a great distance. At such 
times the testicle would swell and become painful in proportion 
to the patient's indiscretions. 

On March 23, 19 14, ten months after the injury, while enter- 
ing his garage, the patient struck the same testicle against the 
end of a two by four timber. The pain which followed this 
second accident was not so severe as that caused by the first in- 
jury. The testicle again became much swollen, and at the end 
of five days reached its present size, which it has maintained ever 
since. Its painfulness depended largely upon the patient's 
position. He is perfectly comfortable when lying on his back. 

On July 15, 1 9 14, the testicle was aspirated for fluid and none 
found. On March 15, 19 14, before the second injury, a specimen 
was removed from the diseased testicle for pathologic examina- 
tion, and the report was as follows: 

The specimen shows an infection granuloma with no evidence 
of maHgnancy. It consists of white fibrous tissue with irregular 
islands of small round-cell infiltration. No submiliary tubercles 
were found. Here and there a necrotic area is present, with a 
moderate accumulation of small cells in the surrounding tissue. 
No histologic structure of testicle is found anywhere in the sec- 
tions. 

The patient has had a cough and an evening rise of tempera- 
ture of from 99° to 101° F. No tuberculin test was made. 
Blood examination showed the hemoglobin to be 90 per cent.; 
white blood-cells, 8500; red blood-cells, 4,500,000; lymphocytes, 
26 per cent.; large mononuclears, 13 per cent.; neutrophiles, 
61 per cent. The systolic blood-pressure is 135; diastolic, 85. 
Chemical and microscopic examination of the urine is negative. 

Dr. Murphy: How long did it take the testicle to enlarge? 

Intern: Four or five days, the patient thinks. 

Dr. Murphy: Did it ever go down again in size from that 
time on? 

Intern: Yes. 

Dr. Murphy: That is the statement I want to get: that the 
testis became enlarged and then subsequently became smaller. 
When did it commence to increase again in size? 



GUMMATOUS TUMOR OF THE TESTICLE II99 

Intern: After the second injury. 

Dr. Murphy: When was that? 

Intern: On March 23, 19 14. 

Dr. Murphy: Ten months after the primary injury. Was 
there any enlargement of the testis noted between the first and 
second injuries? 

Intern: He beKeves it remained about twice the normal size. 

Dr. Murphy: With tuberculosis the rule is that the swelling 
of the epididymis and testis goes back to normal, or nearly to 
normal, after the primary injury. The patients develop first an 
acute swelling of the affected structures immediately after the 
primary trauma. This acute swelling rapidly subsides to normal 
and then, after a free interval, the tuberculoma gradually in- 
creases again in size. Remember, tuberculosis in the testicle is 
not conomonly associated with trauma. 

The pathologist's diagnosis in this case has relatively little 
value, we think, because he did not get much tissue to examine. 
His opinion holds good only for that specimen of tissue which he 
examined. The rest of this tumor may show quite a different 
appearance. Such areas are very frequent in all granulomas, 
tuberculosis, syphiKs, and actinomycosis. A low-grade chronic 
infection by other organisms may produce such a histologic 
picture. Such low-grade infections sometimes occur in growing 
tumors, and one may excise such an inflammatory area from a 
tumor for microscopic examination, either because it is more 
tender than the rest of the tumor, or harder or softer, and thus be 
seriously lead astray by the pathologist's report. 

That is a good history which the intern has written — a good 
straight statement of the case. What resulted from the pa- 
tient's original traiuna? Did he have a hemorrhage into the 
testicle as the result of the book falling on it? According to the 
statements in the history that is apparently what occurred. 
Certainly no sarcoma of the testicle starts within a day or two 
after the initial trauma and attains so rapidly so great a size as 
this testis did. How soon after the injury did the secondary 
changes occur in this hematoma? When did it commence to 
change its character, and in what did this change consist? Did 
VOL, m — 75 



I200 CLINICS OF JOHN B. MURPHY 

a granuloma become engrafted on this hematoma, or has it 
imdergone malignant degeneration? That question no one can 
answer, because the microscopic examination of the first speci- 
men, which was made before the second injury, is not, I believe, 
a reliable specimen of the condition of the rest of the testicle, 
because the pathologist did not have enough tissue to examine. 
He says he did not get tissue resembling testicular tissue at all, 
which means what? That the specimen was not taken from the 
testicle itself, but from a focus of granulation tissue, the hema- 
toma which was reorganized, a white fibrous tissue filled with 
round-cells. If there was a sarcoma present at that time, it lay 
deeper than the spot from which the specimen was taken. 

The next question that comes up is: Where was the original 
enlargement? A rapid swelling of that size within the tunica 
albuginea could not take place without a necrosis of the remaining 
portion of the testicle occurring. Why? Because the tunica 
albuginea is practically an inelastic membrane. If the swelling 
is associated with an acute virulent infection in the testicle, total 
gangrene of the testicle itself, not including the epididymis, 
rapidly ensues. If the swelling remains aseptic, the necrotic 
testis finally disappears by phagocytosis and absorption. If 
there is a streptococcus infection present, such as occurs in con- 
nection with mirnips and scarlet fever, no rupture to the exterior 
of the suppuration occurs, as a rule, but the child suffers with a 
swollen testicle for a few days, and after two or three weeks the 
swelling all disappears and the testicle with it. When one ex- 
amines such a testicle subsequently, whether in a year or ten 
years, one finds nothing but a small mass of connective tissue rep- 
resenting the destroyed testicle. When a severe hemorrhage 
occurs inside the tunica albuginea, the testicle may be destroyed 
by the pressure in just the same way (apoplexia testis). 

[Dr. Murphy made the usual oblique incision over the lower 
inguinal tract and cord and brought out the testis and epididymis 
through the incision.] 

Now you can see how greatly this testicle is enlarged, and how 
free the epididymis is from any pathologic changes. I have not 
said much about the possibility of tuberculosis in this case be- 



GUMMATOUS TUMOR OF THE TESTICLE I20I 

cause, in the first place, we knew that the lesion was located in 
the testis, and that our differential diagnosis must be between 
syphilis and sarcoma; and, in the second place, we have just 
considered the diagnostic points of tuberculosis at length in 
connection with the previous case. (See this issue of the Clin- 
ics, p. 1191.) 

The possibility that this tumor might be a syphiloma we have 
considered very imlikely. There is nothing to speak in favor of 
this diagnosis except the equivocal report of the pathologist, 
and there are many things which speak against it. The patient 
is a man of some judgment and common sense, and yet he abso- 
lutely denies knowledge of an infection or of any previous illness 
resembling syphilis, and I believe he is sincere. Moreover, his 
brother, who is a doctor, and who brings him here, states that he 
is absolutely certain that his brother has never had a venereal 
infection — so certain, in fact, that he considered the doing of a 
Wassermann reaction unnecessary. Therefore, we did only the 
luetin reaction, and it proved negative. The patient has no 
signs of syphilis, either past or present, on his body. His wife 
is healthy and had had no miscarriages, and his children are all 
living and healthy, and show no signs of syphilis. Therefore, 
the diagnosis of sarcoma seems quite certain, even though the 
history of the development of the lesion is not typical for sar- 
coma, but more like the development of a granuloma, which in 
this case could only be syphilis. 

I have asked for permission, in case this tumor turns out to 
be a sarcoma, to follow the excision of the testicle with an im- 
mediate laparotomy and dissect out all the retroperitoneal lymph- 
glands on the left side as far up as the kidney. The patient would 
not grant me this permission, however, and therefore our opera- 
tion, if done at all, will be delayed probably about two weeks at 
least. 

Tramna is the most common etiologic factor of sarcoma in 
the testicle. Another peculiarity of testicular sarcoma is the 
marked tendency of the sarcoma when occurring in the left tes- 
ticle to form metastases in the regional lymph-glands rather than 
by the blood-stream. Sarcoma of the right testicle, in my ex- 



I202 CLINICS OF JOHN B. MURPHY 

perience at least, does not show this same peculiarity. Why it is, 
I do not know, but I have noted the fact repeatedly. It is quite 
common for the lymph-gland located on the left renal vein to 
contain a metastasis from a sarcoma of the left testicle. The 
left testicle, by the way, is much more commonly involved by 
sarcoma than is the right. Whether this is the general experience 
of surgeons, or whether it is peculiar to us, I do not know. 

[Excises the testis, epididymis, and cord as high up as pos- 
sible.] 

I want to make a section of this testicle and see what it shows. 
[Cuts the tumor through the middle.] There is some testicular 
tissue, as you see, still present. The tumor began apparently in 
the middle of the testicle, and has not yet entirely destroyed it. 
I want a photograph made of this specimen to keep for reference. 
I am not yet quite certain what I have here, but I am sure it is 
not a tuberculosis. Certainly it is not the typical sarcoma which 
I expected to find. Instead of a soft, vascular tumor we have a 
solid white area of necrosis without caseation and surrounded by 
a zone which looks like granulation tissue. It does not look like 
any sarcoma I ever operated. I have more than a suspicion that 
it is, after all, a syphiloma, but it has been so long since I have cut 
down on one of these gmnmatous timiors that I shall have to call 
the pathologist to my aid to verify the diagnosis. If this does 
turn out to be a syphiloma, it will be another demonstration of 
the value of the clinical history in diagnosis. The history of 
the development of this lesion was much more like that of a 
granuloma than of a sarcoma. 

Let the record show that there was a complete enucleation of 
the testicle performed; that the tumor was cut in half and showed 
a large mass located in the middle of the testicle, which showed a 
surface necrosis as large as a silver dollar and was surrounded by 
an area of vascularization like that of granulation tissue. 

This is not such a caseous necrosis as would be present in a 
tuberculoma and, moreover, tuberculosis almost never begins 
primarily in the testicle proper. 

[Note. — The pathologist's report on the specimen was that 
it was a gumma. A Wassermann test was accordingly made and 



GUMMATOUS TUMOR OF THE TESTICLE I203 

was reported strongly positive, although the luetin test was re- 
peated and was negative. Since the diagnosis of syphiloma 
seemed certain, no second operation was done, but the patient 
was put on mercury and sodium cacodylate injections. The op- 
eration wound healed by complete primary union and the patient 
has had no further chnical manifestations up to the present time, 
October 21, 19 14. — Ed.] 



PERFORATING DUODENAL ULCER FIXED TO 
THE ANTERIOR ABDOMINAL WALL.— EX- 
CISION OF THE ULCER.— GASTRODUO- 
DENOSTOMY 



HISTORY 

The patient is a married woman, aged fifty-eight years. 
Her family history is negative regarding tuberculosis and carci- 
noma. She has had the diseases common to childhood, and she 
has had also several attacks of chills and fever, which occurred 
between the ages of twenty and forty. She had an arthritis, 
probably metastatic, in 1886 and 1887, following an acute ton- 
sillitis ten days prior. This arthritis involved ^'all the joints." 
The patient had a hysterectomy performed eight years ago be- 
cause there was a suspicion, though not a certainty, of cancer 
being present. She has never had typhoid fever. Menstruation 
began at seventeen and continued regularly until the menopause 
at fifty. During the last year of menstruation she menstruated 
every third instead of every fourth week, four days* duration, 
three napkins a day. She never had any intermenstrual flow 
and never any excessive flow. 

Her present illness dates back to June, 1914. One day she 
experienced a burning sensation, which seemed to extend all 
over the abdomen. This occurrence was repeated the next day. 
With this second attack she developed an aching pain about the 
middle of the abdomen, but a little toward the right side. This 
pain has continued up to the present time. There have been 
intervals of from three to seven days when she has been free from 
pain. The pain was never acute and agonizing or felt distinctly 
localized over McBumey's point or under the right costal arch. 

She has always digested her food well, and has had little or 
no belching or eructations of acid after meals. Her appetite is 

1205 



I206 CLDnCS OF JOHN B. MURPHY 

good. Her bowels are very constipated. She does not know 
whether she has ever passed clay-colored stools. 

Three weeks ago, on a Wednesday, the patient arose at 6 
A. M., feeling worse than usual, the pain in her abdomen having 
been more constant in the past two weeks. A few niinutes after 
the patient was up she felt a very violent pain disseminated all 
over the abdomen. There was no focal localization of the pain, 
with the exception that it very soon radiated to the right shoulder. 
She perspired markedly, and the pain became so intense that a 
doctor was called to see her twenty minutes after the onset of the 
attack. He administered a hypodermic injection, which some- 
what relieved the pain. This injection was repeated in two hours. 
The patient has been in bed most of the time since this attack, 
with almost constant pain in the middle of the abdomen and a 
little to the right. She had no fever, chills, or jaundice with 
this attack. The bowels moved normally the day following the 
onset. She has had no increased frequency of urination, and 
no blood in the urine or stools. 

Examination by Dr. Murphy showed increased resistance over 
the gall-bladder region. This resistance felt like a mass, but 
when the muscles relaxed, the mass disappeared. The margin 
of the liver could not be outlined by palpation on account of the 
resistance and soreness in the right hypochondrium. 

Since the last attack the patient has been very sensitive to 
pressure under the right costal arch. For this reason she has 
discontinued wearing her corset. 

COMMENTS AND OPERATION 

Dr. Murphy (September 17, 1914): Where was the soreness 
during the acute attack? 

Intern: The soreness was all over the abdomen, and finally 
settled in the upper abdomen on the right side. 

Dr. Murphy: That is an atypical history. It does not en- 
able us to make a definite diagnosis. When I examined her, she 
had almost all her sensitiveness in the gall-bladder region. 
When I placed my hand there I thought I felt a tumor, but as I 
kept my hand there, pressing gently, and, at the same time, got 



DUODENAL ULCER FIXED TO ABDOMINAL WALL I207 

her attention away from it, by continuing to question her about 
her iUness, the tumor seemed to disappear. In other words, it 
was rigidity of the abdominal muscles which produced the feeling 
of resistance, and not a tumor. 

She has had a hysterectomy performed for a lesion of the 
uterus suspicious of malignancy. I do not know that a micro- 
scopic examination was made at the time of the operation. She 
has not had the usual cycle of complaints that precede a severe 
attack of cholecystitis, nor has she had any jaimdice. She has 
had how many attacks of pain? 

Intern: This is the only serious attack. 

Dr. Murphy: What elevation of temperature did she have 
in this attack? 

Intern: About 100° or 100.5° F. — no higher than that. 

Dr. Murphy: This attack was when? 

Intern: Three weeks ago. 

Dr. Murphy: We have not come to a positive diagnosis in 
this case. It is, however, clearly a *' surgical abdomen," and we 
expect our operation not only to clear up the diagnosis, but also 
to relieve the condition present, whether it lie in the gall-bladder, 
stomach, or duodenum. I do not suspect a pancreatitis, because 
the attack has not been severe enough to justify that diagnosis, 
and the tenderness is not in the pancreatic region. For a meta- 
static malignancy of the liver — from her former supposed can- 
cer of the uterus — the pain has been too great and too variable. 
Fever and absence of liver enlargement also speak against malig- 
nancy. For an acute lesion in the right kidney the urine and the 
ic-ray, together with the clinical history and fist percussion over 
the loin, leave us without a shred of evidence. We must, there- 
fore, conclude that the gall-bladder, the duodenum, and the py- 
lorus are the spots which demand our closest scrutiny on opening 
the abdomen. We may also examine the appendix, although we 
have no legitimate reason to suspect its involvement. The loca- 
tion of the pain, its great severity and reference to the shoulder, 
the slight fever, absence of vomiting, and long persistence of the 
symptoms without abscess formation look like an upper abdomi- 
nal lesion and not an appendicitis. 



I2o8 CLDJICS OF JOHN B. MURPHY 

[Dr. Murphy makes a right paramedian incision in the epi- 
gastrium and opens the abdomen. The gall-bladder comes into 
the field.] 

Dr. Murphy: Here is the site of the old inflammatory attack. 
See the white gall-bladder! That whiteness means avascularity 
and connective tissue. Now let us make the further examina- 
tion. First I am examining the condition of the kidney on this 
right side. It is fixed. There is no enlargement. Now, as I 
go down toward the appendix, I come into trouble. There is an 
obstruction to my progress downward from the gall-bladder at 
the position in the right hypochondrium where this patient has 
had her greatest sensitiveness. There is an adhesion here which 
has fixed the intestine firmly to the anterior abdominal wall. 
Let us draw out the stomach and determine its condition. It 
is not enlarged, but as we come to the pylorus we find it bound 
into this mass, which is adherent to the anterior abdominal wall. 
It looks to me as though there has been an ulceration at or near 
the pylorus, with perforation or perigastritis and fijcation of the 
pyloric zone and the duodenum to the anterior abdominal wall, 
where we noted the sensitiveness on palpation before operation. 

I must enlarge the abdominal incision downward, in order to 
expose and separate this attachment to the anterior abdominal 
wall, and to determine whether the fixation is due to a gastric or 
duodenal ulcer or to a gastric malignancy. The symptoms have 
been so acute that they speak in favor of its being a duodenal 
ulcer rather than a cancer of the stomach. One can see readily 
why the tumor should disappear when the patient relaxes, be- 
cause it is fixed to the anterior abdominal wall, and is put imder 
tension when the patient's abdominal muscles are contracted, 
and is relaxed as soon as the muscle pull ceases. That makes 
the significance of the physical signs quite clear. Now that I 
have enlarged the incision and partly freed the mass, it is evident 
that it is the duodenum which was primarily involved, and not 
the stomach. A carcinoma in the duodenum is a very rare lesion, 
but an ulcer in the duodemun is a very common one. The mass 
of adhesions appears to be merely of inflammatory origin. They 
are firm and fibrous, and I see nowhere any nodules which could 



DUODENAL ULCER FIXED TO ABDOMINAL WALL 1209 

be taken for the outrunners of a carcinomatous process. This is, 
therefore, evidently a perforating duodenal ulcer, which has come 
up to the anterior wall of the abdomen and become fixed there, 
either shortly before or just after perforating. The significance 
of the clinical history is now quite clear. The patient's early and 
relatively mild attacks of pain were the manifestations of a local 
peritonitis — a periduodenitis — preceding the actual perforation, 
which finally occurred three weeks ago and gave rise to a more 
extensive peritonitis, which, however, did not become generalized. 
We must separate this mass from the anterior abdominal wall, 
and must protect the peritoneal field as we do it. We shall take 
out the parietal peritoneum with the inflammatory tirnior, and 
later perform a plastic on the peritoneum to cover the raw surface 
left. A desmoid beginning in the rectus muscle might grow 
through the abdominal wall into the peritoneum and become 
attached to the front of the duodenum; but a desmoid is a prac^ 
tically painless tumor, and is of very slow growth. I noticed a 
patient sitting up in the audience this morning — a trained nurse 
on whom I operated for a desmoid about a year and a half ago. 
A desmoid usually follows confinement when it occurs in this 
position. 

The pancreas, as you see, lies close behind this mass. We 
have a full exposure of the field here so that we can resect the 
ulcer. Here is the pancreaticoduodenal artery just below the 
ulcer. [Dr. Murphy makes an oval longitudinal incision in the 
duodenum around the adherent area and excises it.] There is 
the ulcer — a punched-out affair, with thick, calloused margins. 
I can see no sign of malignant degeneration. We are going to sew 
up this wound transversely, so that it will not diminish the diam- 
eter of the Imnen of the duodenum, but, rather, increase it. I 
shall also perform a gastroduodenostomy by taking out half of 
the pylorus, which makes one operation in place of two, since I 
merely have to continue my first incision to complete the gastro- 
duodenostomy, and thus avoid the necessity of performing a 
gastrojejunostomy. 

I am making as accurate a suture as possible, looping each 
stitch through, so as to get the best hemostasis that we can in 



I2IO CLINICS OF JOHN B. MURPHY 

closing the wound in the pylorus and duodenum. [Demonstrates 
the specimen to the clinic] This is a very pretty, rather acute, 
duodenal ulcer. There has been an attempt at perforation into 
the free peritoneal cavity, and the ulcer would have perforated 
into the free peritoneal cavity if it had not become adherent to 
the anterior abdominal wall. Had she a history of previous 
duodenal trouble before these attacks of periduodenitis set in? 

Intern: No. Not at all. 

Dr. Murphy: This is, then, one of those not infrequent cases 
of latent duodenal ulcer. When the clinical history fails us in 
cases of duodenal ulcer it leaves us indeed at sea as to means with 
which to make our diagnosis. Exploratory laparotomy is, then, 
our sole recourse. The advantage of Pagenstecher's linen, which 
I am using for these through-and-through sutures, is that it has 
practically no capillarity. Its capillarity is destroyed in the 
preparation. Consequently it does not transmit septic fluid 
from the interior of the alimentary tract to the peritoneal surface 
when used as a through-and-through suture. 

[Removes the clamps from stomach and duodenum and in- 
serts a continuous Lembert stitch transversely across the line of 
the gastroduodenal junction.] 

I used the Connell inversion stitch in my through-and- 
through sutures, and I have left the lumen of the duodenum larger 
than it was before I excised the ulcer. Following this continuous 
Lembert whip stitch we are putting in some interrupted tacking 
stitches to take the tension off the deeper stitches. 

We have not yet found an explanation for the ancient chole- 
cystitis of this patient. She has no gall-stones and she has not 
had this ulcer for a long enough time, we believe, to lead to a gall- 
tract infection. We know that typhoid fever is the most com- 
mon cause of cholecystitis, and appendicitis the next most 
common. Following these two chief causes come gastric and 
duodenal ulcer and then ulcer of the large intestine. 
' '^ I am using the gastrocolic omentum to cover the angle sutures 
— always dangerous spots, because of their liability to leakage. 
I am carefully suturing the pylorus and duodenum back over the 
pancreas. Pancreatic leakage is one of the most serious acd- 



I 



DUODENAL ULCER FIXED TO ABDOMINAL WALL I2II 

dents which can occur m the upper abdomen, and I am taking no 
chance here on its happening to this patient. I shall still further 
add to the security against duodenal or pancreatic leakage by 
stitching the omentum over this area. It protects this field 
entirely. 

It still remains to cover the denuded area on the anterior 
wall of the abdomen, where the ulcer was adherent. If we do 
not do so, a fresh adhesion will soon form at this spot. Our 
method of procedure is simple, but effective. We simply dissect 
up the adjacent peritoneum and stretch it over the defect, sutur- 
ing it in place with the continuous catgut suture which we use to 
dose our peritoneal incision. 

This was a very pretty case, first, because we were unable to 
arrive at an absolutely definite conclusion from the clinical his- 
tory, in spite of the fact that the clinical history fitted the patho- 
logic condition exactly. This is another illustration of the great 
value of an exact anamnesis in these upper abdominal cases. 
Pretty, in the second place, because of an unusual physical sign, 
the abdominal tumor disappearing when the patient relaxed, 
which made one feel certain that the tumor was not a gall- 
bladder. It was a mass attached to the anterior abdominal wall, 
and when muscular relaxation occurred, it receded. The diag- 
nosis of a perforating duodenal ulcer fixed to the abdominal wall 
was not made, and yet the significant facts were staring us in the 
face all the time — almost shouting for recognition. How futile 
to call in the laboratory man and the rr-ray man! How unneces- 
sary to send for the stomach-tube, the gastroscope, or to expose 
the patient in the fluoroscope to repeated doses of the ic-ray and 
bismuth soup ad nauseam, when the clinical history and the 
physical examination tell the story more quickly, more clearly, 
and more reliably ! These accessories have great value to verify 
diagnoses. Diagnosis cannot be machine made. This time we 
guessed that this might be a duodenal ulcer. The next time we 
shall know. That is the great value of clinical experience, the 
estabhshing in the cortical cells of a sort of rogue's gallery of 
disease — the mental pictures of pathologic conditions, one after 
another, each with its appropriate cognomen. Thus we are 



12 12 CLINICS OF JOHN B. MURPHY 

able eventually to "spot" all the old rogues, and when a new 
offender appears, as today, we can at least tell from its "mug" 
to which gang it belongs. 

The temperature she had, as you remember, was recorded as 
about ioo° F. That degree of fever would be about right for 
this type of ulcer, which, although it perforated, became adherent 
and walled off almost immediately, and whatever peritoneal 
exudate formed, drained into the inside of the duodenum through 
the ulcer. 

The shock should be very slight after this operation, because 
the pyloric zone was elevated completely out of the peritoneal 
cavity in doing the work. It came out very readily, thus enab- 
ling us to wall off the peritoneum completely and protect the in- 
testines from exposure to the air. When the intestines are ex- 
posed to the air, they rapidly give off carbon dioxid, and the re- 
sulting akapnia causes the phenomena which constitute shock, 
as Yandell Henderson has shown by his beautiful series of experi- 
ments. Since Henderson discovered this important fact in the 
physiology laboratory, surgeons almost everywhere have con- 
firmed his observations. Shock after abdominal operations varies 
in direct ratio with the degree and duration of exposure of the in- 
testines to the air. The surgeon who keeps the intestines out 
of the field of operation with all possible care cannot be made 
to consider postoperative shock a live question in abdominal 
surgery. 

Sometimes the pylorus is not nearly so mobile, especially when 
the ulcer is located close to it and lies on the posterior wall, where 
it readily forms adhesions to the structures behind it. 

[The usual closure of the abdominal wound followed.] 

Let the record show that the ulcer lay upon the duodenal side 
of the pylorus, and was, therefore, interpreted as non-malignant; 
that after the excision of the ulcer there was a transverse union 
made of the duodenum to the stomach, first suturing the wall 
through and through, including all the coats — a Czerny suture of 
Pagenstecher linen; that the next suture was of Pagenstecher 
linen, and the superficial suture of catgut; that the area of suture 



DUODENAL ULCER FIXED TO ABDOMINAL WALL 1213 

was entirely covered over with omentum, so that there was no 
raw surface left exposed at the line of union. 

The patient will be put on proctoclysis, and will have nothing 
by mouth for three or four days. By that time she will have an 
organic adhesion formed along the Une of suture. 

[Note. — The microscopic examination of the excised ulcer by 
our pathologist, Dr. Sweek, verified Dr. Murphy's diagnosis on 
the gross specimen, that it was non-malignant. A bacteriologic 
examination of the ulcer-wall by Rosenow's method failed to 
reveal pathogenic microoganisms. All the cultures remained 
sterile. — Ed.] 

[Note. — The woimd healed by complete primary union. 
The patient made an entirely uneventful recovery and left the 
hospital October 8, 1914. — Ed.] 



RETROPERITONEAL SARCOMA OF THE UP- 
PER ABDOMEN, FILLING UP THE LESSER 
PERITONEAL CAVITY.— EXPLORATORY LAP- 
AROTOMY 

HISTORY 

The patient, a widower aged fifty years, entered the hospital 
with the following history: His father died of sarcoma at the age 
of eighty-six. He has two brothers living who have tuberculosis, 
but both are doing well at present. The patient had malaria 
at the age of nine, and was jaundiced for three weeks following the 
attack. He had tonsilHtis and la grippe in 1890. In May, 1893, 
he had an initial lesion, a single hard sore, on the penis. Three 
weeks later he developed another one, and so on, until six ap- 
peared in all. A crust formed on each lesion a few days after 
its appearance, and pus formed beneath the crust. By Sep- 
tember, 1893, they were all healed. The patient consulted a 
doctor, who said they were not chancres, and no treatment was 
given. In 1898 — five years later — he had an attack of choroidi- 
tis which improved under antis3^hilitic treatment. In August, 
19 13, he had a Wassermann test made, which was reported 
''slightly positive." 

His present trouble began three years ago (191 1), when he lost 
25 pounds in weight, felt badly, had no appetite, suffered a gen- 
eral breakdown in health, with a loss of energy and an occasional 
evening rise of temperature to 99° F. He had no chills, cough, 
or night-sweats. His pulse-rate was 78. For the following two 
years he felt better, but the evening rise of temperature continued. 

In December, 1913, while in bed, he had a very severe pain 

in the lower left quadrant of the abdomen, lasting about thirty 

minutes. It also extended through to the back. He also had 

pain referred to the head of the penis and to the left testicle. 

VOL. in — 76 12 IS 



I2l6 CLINICS OF JOHN B. MURPHY 

He had no chills, fever, or vomiting. He voided urine shortly 
after the attack. Microscopic examination of this urine showed 
no blood. 

On January 20, 19 14, the patient noticed a mass, which he 
thought was resistant to pressure, covering an area as large as 
an adult's hand in the epigastrium. This timior moved with 
respiration, but was scarcely noticeable on deep inspiration. 
This mass increased to double its original size in three weeks. 
A Wassermann test at this time was negative. The patient was 
not under specific treatment. 

On February 15, 1914, he consulted a doctor who told him 
that he had an inoperable cancer of the stomach. The Wasser- 
mann test was again negative. He took active treatment with 
salvarsan and mercury. The mass kept gradually increasing in 
size. Again, in June, 19 14, while still under antisyphilitic treat- 
ment, the Wassermann test was negative. 

In the mean time he consulted another doctor, who said that 
he had a tumor of the liver and not of the stomach. Not being 
satisfied with these different diagnoses, he consulted still another 
doctor, who told him he had probably a cyst of the pancreas and 
advised an exploratory laparotomy. 

At present the enlargement is approximately eight inches in 
diameter transversely, and is located slightly to the left of the 
median line, in the epigastric region. It has never caused much 
discomfort with the exception that once in a while he notices a 
sharp shooting pain in the region of the enlargement. This pain 
lasts only a few seconds at a time. The tumor is not hard or 
woody to the touch. 

The patient remembers having had, at the age of ten years, 
a hyperacidity and "turning of the stomach," with a recurring 
regurgitation of food which has continued to the present time. 
In the past month he regurgitated stomach contents at every meal 
and noticed at times that he brought up articles eaten the day 
before. He has epigastric discomfort from three to six hours after 
eating. He has no actual pain, but much belching of gas, al- 
though practically never nauseated. He vomited in June, 1914, 
for the first time. He thinks it was due to " physical exhaustion." 



RETROPERITONEAL SARCOMA OF ABDOMEN 1217 

Up to last year the patient has been more or less constipated, but 
since that time his stools have become soft and sometimes watery. 
No blood has been seen in them. He has two bowel movements 
a day, as a rule. These are very inconsistent as to color. He has 
never passed clay-colored stools. He has had a sUght cough, 
with a clear mucoid sputum, for the last three months, and an 
occasional evening rise of temperature to 99° F. or slightly higher. 
He has lost 10 pounds in the last eight months. 

COMMENTS AND OPERATION 

Dr. Murphy (September 5, 1914): His father died of sar- 
coma of what? 

Intern: The peritoneum. 

Dr. Murphy: When did he have the jaundice? 

Intern: Following the attack of malaria at the age of nine 
years. It lasted for three weeks. 

Dr. Murphy: Was there any pain associated with it? 

Intern: No. 

Dr. Murphy: What kind of treatment was administered for 
the choroiditis? 

Intern: Constitutional treatment, chiefly mercury. 

Dr. Murphy: How soon after that attack of pain in the left 
lower quadrant did he notice the tumor? 

Intern: About a month. 

Dr. Murphy: How severe was the abdominal pain? 

Intern: Very acute. 

Dr. Murphy: Go on, tell me about it. What do you mean 
by *'very acute"? How long did it continue? 

Intern: He was in bed when the pain took him. The pain 
continued very severe for about fifteen minutes, and finally dis- 
appeared after about thirty minutes had elapsed. 

Dr. Murphy: Did all the soreness disappear? What one 
wants to estimate in such a case is what relation the pain bore to 
the tumor he has now in the epigastrium. Was there a pan- 
creatic rupture or an acute hemorrhage, or a hemorrhagic pan- 
creatitis? Was the pain the sign of an embolus lodging in the 
pancreas, and, perhaps, bringing infective material with it? 



I2l8 CLINICS OF JOHN B. MURPHY 

Was this pain a purely functional something that entirely passed 
away in fifteen minutes, leaving no train behind? Or did it stand 
in a causal relationship to the fact that a month later he came to 
the doctor complaining of a tumor in the same location in which 
he had had the pain? If the cause of this pain was an acute 
pancreatitis, the pain would have lasted longer than fifteen 
minutes — much longer. He would have been sick in bed, and 
very sick. If it was an embolus in the pancreas, that is another 
matter. Such a pain might have lasted for only a few minutes if 
the embolus was small and bland. Then, again, the pain may 
have been, and probably was, due to some occurrence entirely 
outside the pancreas. How much temperature has he had lately? 

Intern: 99° F. or a little over. 

Dr. Murphy: 99° + F., but never to 100° F. That is the 
only elevation of temperature he gets. I saw him originally be- 
fore I went on my summer vacation this year. I saw him then 
in consultation with Dr. Mix. 

The first question which comes up here is: Is this a carcinoma 
of the stomach? The patient has not lost much weight. He 
has not had the usual train of symptoms of carcinoma of the 
stomach. Still we all know that in the cases of diffuse carcinosis 
of the stomach one may have a great tumor filling all the upper 
abdomen, with very little gastric symptomatology or general 
intoxication. I am speaking of the intoxication that comes from 
the cellular products of the cancer. It was our interpretation of 
the symptomatology and findings that this was a lesion either of 
the pancreas or directly adjoining it. It was, further, our inter- 
pretation that it was not a syphilitic lesion, because the patient 
has had no. recent sign of active syphiHs, and all the time his 
Wassermann test has been negative. I do not recall that we made 
a luetin test in this case. The rule is that we make both tests on 
suspected syphilitics — that is, we make the luetin inoculation 
and the Wassermann reaction synchronously. We are interested 
at present to see how they will check up with each other, as well 
as with the clinical findings. The luetin test is by all odds the 
easier done of the two, and yet it requires training to tell the 
blushing that comes following the Noguchi test in the normal in- 



RETROPERITONEAL SARCOMA OF ABDOMEN 1219 

dividual from that in the syphilitic who does not develop the 
t)rpical papule and vesicle. 

[Demonstrates the patient to the clinic] 

You can see this epigastric tumor from a distance. The 
urine examination is negative. There is no blood in the feces. 
Examination of the gastric contents after a test-meal is negative. 
This man is a doctor. He has made the complete medical Hej- 
ira. He has also been around town here all summer, and I 
think he has consulted about everybody in town, and still is not 
certain as to what he has. He finally concluded to come back 
here and have an exploratory operation performed. It appears 
to me, on examining him, that I can cut in between the left lobe 
of the Kver and this timior. It feels to me as though there is 
superficial fluctuation either in or over the tumor. It may 
possibly be in some hollow viscus that rests on a more solid tumor. 
The tumor itself is irregular and nodular. It is movable on the 
surrounding structures. You will find, from a perusal of the 
hterature, that in many instances a tumor of the spleen is im- 
movable and also, in many instances a tumor of the pancreas 
may be movable. Of course, the rule is just the contrary. I 
can push this tumor quite a distance down in the abdomen. 
The patient has nothing in his history to indicate the possibiHty 
of an echinococcus infection, nor does palpation reveal anything 
like the characteristic thrill. 

[Left paramedian incision in the epigastrimn after the usual 
manner.] 

The stomach is resting in front of this timior. That is the 
fluctuating mass which I felt over the timior when palpating the 
abdomen. The tumor comes up from behind and displaces the 
stomach downward. This is the gastrohepatic omentum which 
one sees here, making this thin covering for the tumor. The 
tumor appears to be bulging up through the lesser peritoneal 
cavity. I will dislodge the stomach downward because access 
to the tumor appears easier from above the stomach than from 
below through the gastrocolic omentum. The tumor extends 
far over on to the left side of the abdomen, behind the stomach, 
and hes on the left kidney, but is not attached to it. It appears 



I220 CLINICS OF JOHN B. MURPHY 

to rest chiefly on the pelvis of the kidney. It appears to fill up 
the entire lesser peritoneal cavity. It is of enormous size. I 
cannot say that it fluctuates anywhere. The right kidney is 
free. The tumor is not attached at all to the hver. The rela- 
tions of the tumor, and its growth into the lesser peritoneal cav- 
ity, speak strongly for an origin in or immediately around the 
pancreas. Can we and shall we remove this tumor? If so, how? 
Above the stomach seems the easier route by which to attack it. 
The great mass of it Ues directly behind the stomach, which we 
must exert great care not to injure. 

[Cuts through the gastrohepatic omentum, exposing the 
surface of the tumor.] 

The tumor comes up from behind the peritoneum, pushing 
the peritoneum in front of it. That practically means a pan- 
creatic origin in this location. I will try to aspirate it and see 
if it is a cyst. If it is a solid tumor, we shall have to do some 
more soHd thinking to scheme out its removal. We cannot 
take it out through this upper route because this is an exploratory 
route. We should do too much damage to surrounding structures 
if we should do our excision by working above the stomach. 
The tumor nowhere seems to fluctuate. It feels rather like a 
sarcoma, I should say. You know that pecuHar feeling of firm- 
ness and elasticity which a sarcoma has as compared to the 
doughy friability of a large carcinoma. Now I am aspirating 
the tumor at this point, rather low down. [Only a little blood 
and bloody tissue is removed.] Now I shall aspirate at this 
other point, higher up. [The same result.] See the soft tissue 
which has exuded through the puncture wound! That means 
that this is, in all probability, a retroperitoneal sarcoma filling 
up the lesser peritoneal space. It is not a cyst. Now let us make 
still another puncture above. The same result again. That 
means what? Close him up! Will I take the tumor out? No. 
When I say a retroperitoneal sarcoma, remember that I do 
not define whether it is or is not in the pancreas. I am inclined 
to think it is a tumor of the pancreas. If it is, and arises from 
the glandular tissue, it ought to be of the adenomatous or 
adenocarcinomatous rather than of the sarcomatous type. 



RETROPERITONEAL SARCOMA OF ABDOMEN 



I22I 



If it originated behind the pancreas, it is most likely a lympho- 
sarcoma, this being the most frequent type of large sarcoma 
that occurs in this position. 

I should like to take out a piece of this tumor for micro- 








Fig. 381. — Retroperitoneal spindle-cell sarcoma arising in the pancreas and 
pushing its way forward between the stomach and the liver. The dark color of the 
tumor showing through the gastrohepatic omentum is an index of its great vas- 
cularity. 



scopic examination, but * Conscience makes cowards of us 
all." If I did that, it would mean blood, blood, blood! It is 
bleeding a lot, as it is, from the needle punctures, so you can 
imagine what it will do from an excision of a sizable piece of it. 

[The usual closure of the abdominal wall layer by layer 
followed.! 



1222 CLINICS OF JOHN B. MURPHY 

There is very much tension on this peritoneum, for Sister 
has kept the patient as lightly under as possible; therefore I 
have to exercise great care not to tear it as I put in this first 
continuous suture. [Puts it in.] I will next follow that row of 
stitches rapidly with the next row, through the fascia. [Puts 
it in.] Now I am safe. The wound will not tear open now. 

Let the record show that on opening the abdomen it was 
found that the tumor lay behind the stomach; that the super- 
ficial fluctuation which we noticed on palpation was due to 
that fact; that a manual examination was made of the lower 
surface of the tumor, and that both the right and the left kidney 
were found free; that the left pole of the tumor rested on the 
left kidney, or, rather, at the hilum of the kidney, but was not 
attached to it; that the right pole of the tumor rested on the 
right kidney; that the tumor projected upward as an encapsulated 
mass against the gastrohepatic omentum; that the surface of 
the tmnor was glistening so that it could be easily seen through 
that thin membrane; that this omenttmi was opened and an 
examination made of the tmnor, which was found not adherent 
in front; that it originated entirely from behind the peritoneiun; 
that on its anterior surface it presented the appearance of com- 
pressed pancreas; that the pancreas was not palpable in its 
usual location; that three aspirations were made of the tumor, 
and small pieces of tumor tissue withdrawn with the aspirating 
needle; that we thought it to be a retroperitoneal sarcoma, 
and that the abdomen was closed without making any attempt 
to remove the tumor. 

I am making a very accurate approximation of the fascia, 
as it is my impression that it is more difficult to get a good union 
of the rectus aponeurosis in the upper half of the abdomen than 
it is in the lower half. I had a letter in my mail just this morning 
from a doctor asking me about my experience on this point, 
since he is writing a paper on the subject, and his inquiry rather 
crystallized my views on the subject as I looked back over my 
cases. 

The report from the pathologist on the pieces of tissue which 
were removed with the aspirating needle is that they show a 



RETROPERITONEAL SARCOMA OF ABDOMEN 1 2 23 

spindle-cell sarcoma. That settles the matter, and confirms 
our judgment in refusing to attempt excision. If we took out 
the tumor and he Kved through the operation, he had nothing 
to hope for in the line of permanent recovery. A spindle-cell 
sarcoma in this location is certain to recur after operation — for 
it is impossible to get out all its creeping ramifications in this 
location. Sarcoma of the pancreas is a rare lesion, particularly 
in comparison with carcinoma, which we see every now and 
then. And yet the observations of pancreatic sarcoma re- 
corded in the literature of pathology and surgery are already 
fairly numerous. The varieties most frequently seen are the 
spindle-cell type, which we have here today, the round-cell 
type, the angiosarcoma, and the myxosarcoma. Korte has 
devoted considerable attention to these rare tumors of the 
pancreas and gives us a good account of them, together with 
a summary of the standard literature concerning them, in 
his volume on the Surgery of the Pancreas in the Deutsche 
Chirurgie. 

[Note. — The wound healed by complete primary intention 
and the patient left the hospital at the end of about two and a 
half weeks.l 



INDEX TO VOLUME III 



Abderhalden test in pregnancy, Dec, 
1087 
technic, Dec., 1089 
in tubal pregnancy, April, 206 
Abdomen, upper, retroperitoneal sar- 
coma of, Dec., 1215 
history of case, Dec., 12 15 
operation in, Dec., 1217 
Abortions, June, 445 
Abscess, appendiceal, postoperative 
ventral hernia following, 
Aug., 861 
history of case, Aug., 861 
operation in, Aug., 862 
perinephritic, Oct., 922 
history of case, Oct., 922 
operation in, Oct., 923 
Adynamic ileus, Aug., 623 

pericholecystitis as cause, Aug., 629 
septic, Aug., 626 
Amebic dysentery, emetin in, April, 198 
Amputation neuroma with ascending 
neuritis, April, 355 
history of case, April, 355 
operation in, April, 356 
of Cauda equina, ascending root 
neuritis following, 
Aug., 705 
history of case, Aug., 

705 
operation in, Aug., 705 
Analyses, gastric, in gastric ulcer and 

gastric cancer, Feb., loi 
Anastomosis, nerve, spinofacial, Aug., 

745, 751 
Anatomy of thyroid gland, April, 285 
Anemia, pernicious, April, 389 
primary, April, 381 

I 



Anemia, secondary, April, 381 
Anesthesia, nitrous oxid, Feb., 96 
Angulation temperature of septic 

cholangitis, Feb., 175 
Ankle, Charcot, Feb., 15, 85 
history of case, Feb., 85 
operation in, Feb., 86 
fracture of, inversion, Oct., 975 
history of case, Oct., 975 
operation in, Oct., 976 
old inversion, Oct., 967, 987 

history of case, Oct., 967^ 

987 
operation in, Oct., 968, 988 
Ankle-joint, flail, Aug., 839, 854 
Ankyloses, multiple, Dec., 1159 
Ankylosis, bony, between tibia and 
patella and femur, Feb., 

49 
history of case, Feh., 49 
operation in, Feb., 50 
between ulna and humerus, follow- 
ing fracture of olecranon, June, 

523 
of hip, Aug.. 696 
history of case, Aug., 696 
operation in, Aug., 697 
of multiple joints, Aug., 690 
history of case, Aug., 690 
operation in, Aug., 696 
of wrists, arthroplasty for, Dec, 
1159, 1173 
of hip, arthroplasty in, Feb., 29 
due to lipping of rim of acetabulum, 
Feb., 29 
history of case, Feb., 29 
operation in, Feb., 30 
partial, Aug., 674 



221; 



1226 



INDEX TO VOLUME III 



Ankylosis of hip, partial, history of 
case, Aug., 674 
operation in, Aug., 676 
of jaw. Murphy's operation for, June, 
611-616 
Anus, imperforate, Oct., 1047 
history of case, Oct., 1047 
op>eration in, Oct., 1047 
Apoplexia testis, Dec., 1200 
Appendiceal abscess, postoperative ven- 
tral hernia following, Aug., 
861 
history of case, Aug., 861 
operation in, Aug., 862 
Appendicitis, acute, cholecystitis, and 
ascending urinary infection, dif- 
ferentiation, June., 452 
Ochsner treatment, Dec, iioi 
cholecystitis, and pyelitis, differentia- 
tion, Dec, I 103 
in pregnancy, Dec, 1085 
history of case, Dec, 1085 
operation in, Dec, 1085 
talk on, Dec, 1097 
Area, duodenal, in duodenal ulcer, 

April, 268 
Arterial supply of parathyroids, April, 

287-290 
Artery, mesenteric, superior, embolism 

of, Aug., 627 
Arthritides, multiple metastatic, Dec, 

"59 
history of case, Dec, 11 59 
operation in, Dec, 11 66 
Arthritis, metastatic, acute, Feb., 49 
of hip, following tonsillitis, Aug., 
681 
history of case, Aug., 681 
operation in, Aug., 683 
Arthrodesis of knee, Aug., 851 
Arthroplasty, elbow, Oct., 1027-1034 
in ankylosis of hip, Feb., 29 
in bony ankylosis between tibia and 
patella and femur, Feb., 49 
between ulna and humerus fol- 
lowing fracture of olecranon, 
June, 523 
of wrists, Dec, 1159, 11 73 



Arthroplasty in metastatic arthritis of 
hip following tonsillitis, Aug., 681 

in partial ankylosis of hip, Aug., 674 

knee, Oct., 1019-1026 

old case, recent report from, Oct., 

lOII 

of hip, Aug., 663, 690, 696 
Autogenous^ vaccines, auto-sensitized, 

Dec, 1 1 19 
Auto-sensitized autogenous vaccines, 

Dec, I I 19 
Axonal contacting, June, 521 



Benign malignant tumors of breast, 

differentiation, June, 413 
Bicomate uterus associated with fibroid, 
pregnancy in, diagnosis of, June, 445 
Bilateral tuberculous epididymitis, Dec, 
1 189 
history of case, Dec, 1189 
operation in, Dec, 1189 
Bladder, papilloma of, April, 337 
fulguration in, April, 351 
tuberculosis of, treatment, Feb., 76 
tumors of, classification, April, 341 
Bone grafting, Feb., 121 
skid, Murphy's, Feb., 26 
transplantation of, Feb., 120, 121 
in sarcoma of tibia, Dec, 1 134, 1135 
indications for, Feb., 123 
Bony ankylosis between tibia and 
patella and femur, Feb.y 

49 
history of case, Feb., 49 
operation in, Feb., 50 
between ulna and humerus follow- 
ing fracture of olecranon, June, 

523 
of hip, Aug., 696 

history of case, Aug., 696 
operation in, Aug., 697 
of multiple joints, Aug., 690 
history of case, Aug., 690 
operation in, Aug., 696 
of wrists, arthroplasty for Dec, 
IIS9, 1173 



INDEX TO VOLUME III 



1227 



Borborygmus in mechanical ileus, Aug., 

650 
Breast, carcinoma of, Feb., 179; June, 

413 
history of case, Feb., 179; June, 413 
operation in, June, 414 
radical operation for, Feb., 179 
male, carcinoma of, June, 569 
history of case, June, 569 
operation in, June, 569 
malignant papillomatous cysts of, 
Aug., 711 
history of case, Aug., 711 
operation in, Aug., 711 
Paget's cancer of, June, 426; Aug., 
769 
history of case, Aug., 769 
operation in, Aug., 769 
tumors of, malignant and benign, 
differentiation, June, 413 
varieties, June, 413 
Bremerman on vesical papilloma, April, 

337 
Brewer on metastatic infections, Feb., 98 
Button operation. Murphy's, in duo- 
denal ulcer, April, 261 



Calculus, perforation of gall-bladder 
by, Fe&.,i73 
renal, symptoms and signs, Oct., 871 
ureteral, symptoms and signs, Oct., 871 
Carcinoma, gastric, Feb., loi 

grafting of, on gastric ulcer, Feb., 

lOI 

of breast, Feb., 179; June, 413 
history of case, i^e&., 179; June, 413 
operation in, June, 414 
radical operation for, Feb., 179 

of hip metastatic from breast, June, 

557 
history of case, June, 557 
operation in, June, 558, 562 
of male breast, June, 569 

history of case, June, 569 
operation in, June, 569 
of penis, Oct., 945, 951 
history of case, Oct., 945, 951 



Carcinoma of penis, operation in, Oct., 
946, 951 
of rectum with ulceration, Aug.^ 

775 
history of case, Aug., 775 
operation in, Aug., 776 
of stomach at cardiac orifice, June, 

459 
history of case, June, 459 
of testicle, Feb., 72 
Paget's, June, 426; Aug., 769 
history of case, Aug., 769 
operation in, Aug., 769 
radium in, Oct., 1057 
relation of trauma to, June, 413 
ic-rays in, Oct., 1057 
Cartilage, semilunar, internal, fracture 
of, Dec, 1 15 1 
and dislocation of patella, Feb.j 

151 

Cartilaginous exostosis of humerus, 
Dec, 1 185 
history of case, Dec, 1185 
operation in, Dec, 1185 
Cauda equina, amputation of, ascending 
root neuritis follow- 
ing, Aug., 705 
history of case, Aug., 

705 
operation in, Aug., 705 
Cerebellar tumor, Aug., 805 
history of case, Aug., 805 
operation in, Aug., 806 
Charcot ankle, Feb., 15, 85 
history of case, Feb., 85 
operation in, Feb., 86 
Cheilotomy, Feb., 39 
Cholangitis, septic, angulation tempera- 
ture of, Feb., 175 
Cholecystectomy, April, 237 
Cholecystitis, acute appendicitis, and 
ascending urinary infection, dif- 
ferentiation, June, 452 
appendicitis, and pyelitis, differentia- 
tion, Dec, I 103 
recurrent, Dec, 1103 
history of case, Dec, 1103 
operation in, Dec, 11 04 



1228 



INDEX TO VOLUME HI 



Cholecystotomy in recurrent cholecys- 
titis, Dec., 1 103 
Cholelithiasis, ^/>r*/, 237 
history of case, April, 237 
operation in, April, 238 
Colles* fracture, old ununited, Aug., 731 
history of case, Aug., 731 
operation in, Aug., 731 
Compound fractures, management of, 

Feb., 19 
Compression, traumatic, of spinal cord, 

laminectomy for, Feb., 161 
Congenital dislocation of patella, Aug., 
817 
history of case, ^Mg., 817 
op)eration in, Aug., 818 
Contraction, Volkmann's, in fractures, 

Feb., 142 
Convulsions in meningitis, Oct., 912 
Coolidge tube, Oct., 1057, 1061 
Corynebacterium granulomatosi ma- 
ligni, Dec, 11 14 
Hodgkini, Dec., 1115 
Cretinism, April, 295 
Crile on nitrous oxid anesthesia, Fd)., 

96 
Cryptogenic peritonitis, paralytic ileus 
from, Aug., Tig 
history of case, Aug., 719 
operation in, Aug., 720 
Cyst, pancreatic, acute, April, 247 
history of case, April, 247 
papillomatous, malignant, of breast, 
Aug., 711 
history of case, Aug., 711 
operation in, Aug., 711 
Cystic duct, stones in, April, 237 



Decompression, suboccipital, for cere- 
bellar tumor, Aug., 805 

Delirium in pneumococcus meningitis, 
Oct., 912 

Diftgnostic wheel, April, 195 

Diaphngroatic hernia, Aug., 635 
pleurisy, ileus and, differentiation, 
Aug.,t2S 



Dislocation, congenital, of patella, Aug., 
817 
history of case, vlttg., 817 
operation in, Aug., 818 
of patella and fracture of internal 
semilunar cartilage, 
Feb., 151 
history of case, Feb., 151 
operation in, Feb., 152 
Murphy's operation for, Feb., 151 
recurrent, of patella, Aug., 839 
history of case, Aug., 839 
operation in, Aug., 839 
Duodenal area in duodenal ulcer, April, 
268 
ulcer, April, 261 
duodenal area in, April, 268 
gastric ulcer and, differentiation, 

June, 428 
history of case, April, 261 
operation in, April, 263 
p)ain in, April, 272 
perforating, Dec., 1205 
history of case, Dec., 1205 
operation in, Dec, 1206 
Duodenojejunal hernia, Aug., 635 
Dynamic ileus, Aug., 629 

lead poisoning as cause, Aug., 629 
tyrotoxicon poisoning as cause, 
Aug., 630 
Dysentery, amebic, emetin in, April, 
198 



Ectopia testis, April, 217 

history of case, April, 217, 219, 231 
operation in, April, 217, 220, 231 
Elbow arthroplasty, Oct., 1027-1034 
Embolism of superior mesenteric artery, 

Aug., 627 
Embryology of thyroid gland, yl/>ri/, 285 
Emetin in amebic dysentery, April, 198 
Eminentia intercondyloidea, Dec, 1x53 
Empyema, diagnosis of, April, 194 

treatment of, April, 203 
Epididymitis, bilateral tuberculous, 
Dec, 1189 
history of case, Dec, 11 89 



INDEX TO VOLUME III 



1229 



Epididymitis, bilateral tuberculous, 

operation in, Dec, 1189 
Epilepsy, grand mal type of, Oct., 934 
Jacksonian, Oct., 933 
masked, Oct., 934 
petit mal type, Oct., 934 
traumatic, Oct., 931 
history of case, Oct., 931 
operation in, Oct., 932 
Epithelioma of penis, Oct., 945, 951 
history of case, Oct., 945, 951 
operation in, Oct., 946, 951 
Examination and analysis of cases, 

April, 191 
Exhibition of cases, Feb., 130 
Exostosis, cartilaginous, of humerus, 
Dec., 1 185 
history of case, Dec, 1185 
operation in, Dec, 1185 
of interarticular surface of upper end 
of tibia, Dec, 1151 
history of case, Dec, 1 151 
operation in, Dec, 1151 
Extra-articular bloodless nailing of 
fragments in fractures in neighbor- 
hood of joints, Feb., 7 
Extra-uterine pregnancy, diagnosis of, 
June, 445 
management of, June, 445 



Fabella, Dec, 1140 
Facial nerve paralysis of congenital 
origin, Aug., 745 
history of case, Aug., 745 
operation in, Aug., 746 
right, paralysis of, Aug., 751 
history of case, Aug., 751 
operation in, Aug., 752 
Fecal fistula, Oct., 957 

history of case, Oct., 957 
operation in, Oct., 958 
impaction as cause of ileus, Aug., 640 
Femur and tibia and patella, bony 
ankylosis between, Feb., 

49 
history of case, Feb., 49 
operation in, Feb., 50 



Femur, lower third, compound fracture 
of, June, 545 
history of case, June, 545 
operation in, June, 545 
Fibroid of uterus, Aug., 653, 761 
history of case, Aug., 653, 761 
operation in, Aug., 762 
prognosis, Aug., 659 
Fibula and tibia, fracture of, exhibition 
of case, Feb., 137-140 
head of, osteoma of, June, 575 
history of case, June, 575 
operation in, June, 575 
Fistula, fecal, Oct., 957 

history of case, Oct., 957 
operation in, Oct., 958 
Flail ankle-joint, Aug., 839, 854 
Flexor tendons and median nerve, trau- 
matic division of, June, 

517 
history of case, June, 517 
operation in, June, 517 
Fracture, Colics', old ununited, Aug., 

731 
history of case, Aug., 731 
operation in, Aug., 731 
compound, management of, Feb., 19 
of lower third of femur, June, 

545 
history of case, June, 545 
operation in, June, 545 
impacted, of external tuberosity of 
tibia, Dec, 11 23 
history of case, Dec, 11 23 
operation in, Dec, 11 24 
in neighborhood of joints, extra- 
articular bloodless nailing of frag- 
ments in, Feb., 7 
of ankle, inversion, Oct., 975 
history of case, Oct., 975 
operation in, Oct., 976 
old inversion, Oct., 967, 987 

history of case, Oct., 967, 987 
operation in, Oct., 968, 988 
of fibula and tibia, exhibition of case, 

Feb., 137-140 
of humerus, exhibition of case, Feb., 
131-135 



I230 



INDEX TO VOLUME IH 



Fracture of internal and external malle- 
olus, Feb., I 
history of case, Feb., i 
operation in, Feb., 2 
semilunar cartilage, Dec., 1151 
and dislocation of patella, 
Feb., 151 
of olecranon, bony ankylosis between 
ulna and humerus following, June, 

523 
of radius and ulna, exhibition of case, 

Feb., 146-148 
of surgical neck of humerus, nailing 

of, June, 531 
of tibia and fibula, exhibition of case, 

Feb., 137-140 
of ulna and radius, exhibition of case, 
Feb., 146-148 
ununited, Feb., 115 
history of case, Feb., 115 
operation in, Feb., 116 
Pott's, Feb., I 
history of case, Feb., 1 
old, Oct., 993 

history of case, Oct., 993 
operation in, Oct., 993 
operation in, Feb., 2 
Volkmann's contraction in, Feb., 142 
Fracture-dislocation of spine at level 
of twelfth dorsal ver- 
tebra, Dec., 1077 
diagnosis, Dec., 1077 
history of case, Dec., 

1077 
operation in, Dec., 1079 
symptoms, Dec., 1077 
subcoracoid, of head of humerus, 
June, 539 
operation in, June, 539 
Fulguration in papilloma of bladder. 



Gall-bladder, enlarged and dilated 
stump of, removal, Feb., 173 
percussion over, Dec., 1108, 11 09 
perforation of, by calculi, Feb., 173 

Gall-stones, April, 237 



Gall-stones, history of case, April, 237 

operation in, April, 238 
Gastric analyses in gastric ulcer and 
gastric cancer, Feb., loi 
carcinoma, Feb., loi 
grafting of, on gastric ulcer, Feb., 

lOI 

ulcer, Feb., loi 
duodenal ulcer and, differentiation, 

June, 428 
grafting of malignant disease on, 
Feb., loi 
Geiger's electric motor, bone-saws, and 

drills, Feb., 127 
Glans penis, epithelioma of, Oct., 945 
history of case, Oct., 945 
operation in, Oct., 946 
Godlee on Lord Lister and antiseptic 

surgery, Feb., 91 
Goiter, April, 285 
etiology of, April, 299 
history of case, April, 285 
operation in, April, 285 
Grafting, bone, Feb., 121 
of malignant disease on gastric ulcer, 
Feb., loi 
Grand mal type of epilepsy, Oct., 934 
Graves' disease, April, 298 
Gummatous tumor of testicle, Dec., 1197 
history of case, Dec., 11 



Head of fibula, osteoma of, June, 575 
history of case, June, 575 
operation in, June, 575 
of humerus, subcoracoid fracture- 
dislocation of, June, 539 
op)eration in, Jutie, 539 
Hematuria, causes of, differential diag- 
nosis, Oct., 874 
in tuberculosis of testicle, Feb., yg 
Hemorrhoids, internal, April, 381 
history of case, April, 381 
operation in, April, 383 
Hernia, diaphragmatic, Aug., 635 
duodenojejunal, Aug., 635 
of testicle in tuberculosis of testicle, 
Feb., 80 



INDEX TO VOLUME III 



123I 



Hernia, retroperitoneal, Aug., 635 
ventral, postoperative, following ap- 
pendiceal abscess, Aug., 
861 
history of case, Aug., 861 
operation in, Aug., 862 
Hip, ankylosis of, arthroplasty in, Feb., 
29 
due to lipping of rim of acetabulum, 
Feb., 29 
history of case, Feb., 29 
operation in, Feb., 30 
partial, Aug., 674 

history of case, Aug., 674 
operation in, Aug., 676 
arthroplasty of, Aug., 663, 690, 

696 
bony ankylosis of, Aug., 696 
history of case, Aug., 696 
operation in, Aug., 697 
carcinoma of, metastatic from breast, 
June, 557 
history of case, June, 557 
operation in, June, 558, 562 
metastatic arthritis of, following 
tonsillitis, Aug., 681 
history of case, Aug., 681 
operation in, Aug., 681 
Hodgkin's disease, Dec, mi 
bacteriology of, Dec, 11 13 
etiology of, Dec, 11 13 
history of case, Dec, 11 11, 11 16 
Humerus and ulna, bony ankylosis be- 
tween, following fracture of olec- 
ranon, June, 523 
cartilaginous exostosis of, Dec, 1185 
history of case, Dec, 1185 
operation in, Dec, 1185 
fracture of, exhibition of case, Feb., 

131-13S 
head of, subcoracoid fracture-dis- 
location of, June, 539 
operation in, June, 539 
sarcoma of, Aug., 783 
history of case, Aug., 783 
operation in, Aug., 784 
surgical neck, fracture of, nailing, 
June, 531 

VOL. Ill — 77 



Hydrocele in tuberculosis of testicle, 

Feb., 80 
Hypertrophy of prostate, Oct., 1035 
history of case, Oct., 1035 
operation in, Oct., 1035 
Hysterectomy in intra-uterine fibroid, 
Aug., 761 



Ileus, Aug., 617 

adynamic, Aug., 623 
pericholecystitis as cause, Aug., 629 
septic, Aug., 626 

diaphragmatic pleurisy and, dififer- 
entiation, Aug., 625 

dynamic, Aug., 629 

lead poisoning as cause, Aug., 629 
tyrotoxicon poisoning as cause, 
Aug., 630 

fecal impaction as cause, Aug., 640 

history of case, Aug., 617 

illustrative cases, Aug., 617 

management of, Aug., 617 

mechanical, Aug., 630 
borborygmus in, Aug., 650 
leukocytosis in, Aug., 651 
physical examination in, Aug., 651 
temperature in, Aug., 651 
tumors of intestines as cause, Aug., 

639 
vomiting in, Aug., 650 
paralytic, from cryptogenic peri- 
tonitis, Aug., 'Jig 
history of case, Aug., 719 
operation in, Aug., 720 
symptoms of, Aug., 617 
varieties of, Aug., 569 
Iliac sigmoidostomy in cancer of rectum, 

Aug., 'j'js 
Imbrication operation for postoperative 
ventral hernia following appendiceal 
abscess, Aug., 861 
Impacted fracture of external tuberosity 
of tibia, Dec, 11 23 
history of case, Dec, 11 23 
operation in, Dec, 11 24 
Imperforate anus, Oct., 1047 



1232 



INDEX TO VOLUME HI 



Iii^>erf orate anus, history of case, Oct., 
1047 
operation in, Oct., 1047 

Infections, metastatic, Feb., 98 

Infectioiis diseases, acute, orchitis com- 
plicating, Feb., 71 

International Surgical Congress, meet- 
ing of, at Mercy Hospital, Aug., 663 

Intestines, tumors of, as cause of me- 
chanical ileus, Aug., 639 

Intrathoracic sarcoma starting from 
vertebral colimm, differential diag- 
nosis, Oct., 883 



Jacksonian epilepsy, Oct., 933 

Jaw, ankylosis of, Murphy's operation 

for, June, 611-616 
Joints, fractures in neighborhood of, 

extra-articular bloodless nailing of 

fragments in, Feb., 7 



Kernig's sign in meningitis, Oct., 904 
Kidney, malignant tumors of, routes of 
metastasis and clinical course, Oct., 

874 
tuberculosis of, Feb., 76; April, 303 

history of case, April, 303 

operation in, April, 304 
Knee, arthrodesis of, Aug., 851 
arthroplasty, Oct., 1019-1026 

old case, recent report from, Oct., 

lOII 



Laminectomy for traumatic compres- 
sion of spinal cord, Feb., 161 
in fracture-dislocation of spine at 
level of twelfth dorsal vertebra, 
Dec., 1077 
Lane plate in compound fracture of 

lower third of femur, June, 545 
Lead poisoning as cause of dynamic 

ileus, Aug., 629 
Leukocytosis in mechanical ileus, Aug., 

651 
Lever and bone skid, Murphy's, Feb., 26 



Ligamentum teres, occlusion of pylorus 

by use of, June, 585 
Lister and antiseptic surgery, Feb., 91 
Lumbar puncture in pneumococcus 

meningitis, Oct., 915 



Macrognathia, Aug., 745 
Malignant and benign tumors of breast, 
differentiation, June, 413 
disease, grafting of, on gastric ulcer, 
Feb., loi 
of testicle, Feb., 72 
papillomatous cyst of breast, Aug., 
711 
history of case, Aug., 711 
operation in, Aug., 711 
tumors of kidney, routes of metas- 
tasis and clinical course, Oct., 874 
of testicle, routes of metastasis and 
clinical course, Oct., 874 
Malleolus, internal and external fracture 
of, Feb., I 
history of case, Feb., i 
operation in, Feb., 2 
Malposition of testicle, April, 217 
Masked epilepsy, Oct., 934 
Mechanical ileus, Aug., 630 
borborygmus in, Aug., 650 
leukocytosis in, Aug., 651 
physical examination in, Aug., 651 
temperature in, Aug., 651 
tumors of intestines as cause, Aug., 

639 
vomiting in, Aug., 650 
Median nerve and flexor tendons, trau- 
matic division of, June, 

517 
history of case, June, 517 
operation in, June, 517 
Meeting of International Congress at 

Mercy Hospital, Aug., 663 
Meningitis, convulsions in, Oct., 912 
Kemig's sign in, Oct., 904 
pneumococcus, delirium in, Oct., 912 
diagnosis of, Oct., 899, 908 
lumbar puncture in, Oct., 915 



INDEX TO VOLUME III 



1233 



Meningitis, pneumococcus, tllche cere- 
brale in, Oct., 911 
treatment of, Oc/., 916 
varieties of, differentiation, Oct., 899 
Menstrual flow, relation of uterine 

tumors to, Aug., 653 
Mesenteric artery, superior, embolism 

of, Aug., 627 
Metastatic arthritides, multiple, Dec, 

"59 
history of case, Dec., 1159 
operation in, Dec., ii66 
arthritis, acute, Feb., 49 
of hip following tonsillitis, Aug., 681 
history of case, Aug., 681 
operation in, Aug., 683 
infections, Feb., 98 
Multiple ankyloses, Dec., 11 59 
joints, bony ankylosis of, Aug., 690 
history of case, Aug., 690 
op)eration in, Aug., 696 
metastatic arthritides, Dec, 1159 
history of case, Dec, 11 59 
operation in, Dec, 11 66 
Miraips, orchitis complicating, Feb., 70 
Murphy's button operation in duodenal 
ulcer, April, 261 
lever and bone skid, Feb., 26 
operation for ankylosis of jaw, June, 
611-616 
for dislocation of patella, Feb., 151 
technic for radical removal of cancer 
of breast, Feb., 179 



Nail, removal of, from right tibia and 

OS calcis, Oct., 1003 
NaiUng of fracture of surgical neck of 

humerus, June, 531 
Nephrectomy in tuberculosis of kidney, 

April, 303 
Nerve anastomosis, spinofacial, Aug., 

745, 751 
facial, right, paralysis of, Aug., 751 
history of case, Aug., 751 
operation in, Aug., 752 
median, and flexor tendons, traumatic 
division of, June, 517 



Nerve, median, and flexor tendons, 
traumatic division of, 
history of case, June, 

S17 
operation in, June, $^7 
paralysis, facial, of congenital origin, 
Aug., 745 
history of case, Aug., 745 
operation in, Aug., 746 
ulnar, neuroma of, April, 369, 375 
history of case, April, 369, 375 
operation in, April, 369, 375 
Neuritis, ascending root, following 
amputation of cauda 
equina, Aug., 705 
history of case, Aug., 705 
operation in, Aug., 705 
Neuroma, amputation, with ascending 
neuritis, April, 355 
history of case, April, 355 
operation in, April, 356 
of ulnar nerve, April, 369, 375 

history of case, April, 369, 375 
operation in, April, 369, 375 
Neuroplasty,^'/M«e, 467 
and tenoplasty in traumatic division 
of flexor tendons and median nerve, 
June, 517 
Nitrous oxid anesthesia, Feb., 96 



Occlusion of pylorus by use of liga- 

mentum teres, June, 585 
Ochsner treatment for acute appendi- 
citis, Dec, iioi 
Olecranon, fracture of, bony ankylosis 
between ulna and himaerus following, 
June, 523 
Orchidectomy with implantation of 
paraffin substitute for testis, Feb., 6$ 
Orchitis complicating acute infectious 
diseases, Feb., 71 
mumps, Feb., 70 
Os calcis and tibia, removal of nail from, 

Oct., 1003 
Osteoma of head of fibula, June, 575 
history of case, June, 575 
operation in, June, 575 



1234 



INDEX TO VOLUME HI 



Osteomyelitis of tibia, exhibition of case, 

Fd>., 143 
Ovaiy, sarcoma of, with rotation of 
pedicle, June, 599 
history of case, June, 599 
oi>eration in, June, 600 
transplantation of, Feb., 124 



Facet's cancer, June, 426; Aug., 769 
history of case, Aug., 769 
operation in, Aug., 769 
Pain in duodenal ulcer, April, 272 
Pancreatic cyst, acute, April, 247 

history of case, April, 247 
Papilloma of bladder, April, 337 

fulguration in, April, 351 
Papillomatous cyst, malignant, of breast, 
Aug., 711 
history of case, Aug., 711 
operation in, Aug., 711 
Parafl&n substitute for testis, Fd)., 65 
Paralysis, nerve, facial, of congenital 
origin, Aug., 745 
history of case, Aug., 745 
operation in, Aug., 746 
of right facial nerve, Aug., 751 
history of case, Aug., 751 
operation in, Aug., 752 
Paralytic ileus from cryptogenic peri- 
tonitis, Aug., 719 
history of case, Aug., 719 
operation in, Aug., 720 
Parathyroids, April, 286 

arterial supply of, April, 287-290 
Patella and tibia and femur, bony anky- 
losis between, Feb., 49 
history of case, Feb., 49 
operation in, Feb., 50 
congenital dislocation of, Aug.,2>l^ 
and fracture of internal semilunar 
cartilage, Feb., 151 
history of case, Feb., 151 
op>eration in, Feb., 152 
history of case, Aug., 817 
Murphy's operation for, Feb., 151 
operation in, Aug., 818 
lecurrent dislocation of, Aug., 839 



Patella, recurrent dislocation of, history 
of case, Aug., 839 
operation in, Aug., 840 
Paterson on gastric analyses in gastric 

cancer and ulcer, Feb., loi 
Penetrating ulcer on lesser curvature of 
stomach, June, 585 
history of case, June, 585 
operation in, June, 589 
Penis, carcinoma of, Oct., 945, 951 
history of case, Oct., 945, 951 
operation in, Oct., 946, 951 
epithelioma of, Oct., 945, 941 
history of case, Oct., 945, 951 
operation in, Oct., 946, 951 
Percussion over gall-bladder, Dec., 1108, 

1 109 
Perforating duodenal ulcer, Dec., 1205 
history of case, Dec., 1205 
operation in, Dec., 1206 
Perforation of gall-bladder by calculi, 

Feb., 173 
Pericholecystitis, April, 237 
as cause of adynamic ileus, Aug., 
629 
Perinephritic abscess, Oct., 922 
history of case, Oct., 922 
operation in, Oct., 923 
Peritonitis, cryptogenic, paralytic ileus 
from, Aug., 719 
history of case, Aug., 719 
operation in, Aug., 720 
Pernicious anemia, April, 389 
Petit mal type of epilepsy, Oct., 934 
Physiology of thyroid gland, April, 285 
Pleurisy, diaphragmatic, ileus and, 

differentiation, Aug., 625 
Pleuritis, purulent, acute, diagnosis of, 
April, 194 
treatment of, April, 203 
Pneumococcus meningitis, deUrium in, 
Oct., 912 
diagnosis of, Oct., 908 
lumbar puncture in, Oct., 915 
tAche c6r6brale in, Oct., 911 
treatment of, Oct., 916 
Poisoning, lead, as cause of dynamic 
ileus, Aug., 629 



INDEX TO VOLUME III 



1235 



Poisoning, tyrotoxicon, as cause of 

dynamic ileus, Aug., 630 
Portal vein, thrombosis of, Aug., 628 
Postoperative ventral hernia following 
appendiceal abscess, 
Aug., 861 
history of case, Aug., 861 
operation in, Aug., 862 
Pott's fracture, Feb., i 

history of case, Feb., i 
old, Oct., 993 

history of case, Oct., 993 
operation in, Oct., 993 
operation in, Feb., 2 
Pregnancy, Abderhalden test in, Dec., 
1087 
technic, Dec, 1089 
appendicitis in, Dec, 1085 
history of case, Dec, 1085 
operation in, Dec, 1085 
extra-uterine, diagnosis of, June, 445 

management of, June, 445 
in bicornate uterus associated with 

fibroid, June, 445 
tubal, Abderhalden test in, April, 206 
Prostate, hypertrophy of, Oct., 1035 
history of case, Oct., 1035 
operation in, Oct., 1035 
tuberculosis of, Feb., 75, 76, 81 
Prostatectomy in hypertrophy of pros- 
tate, Oct., 1035 
Puncture, lumbar, in pneumococcus 

meningitis, Oct., 915 
Purulent pleuritis, acute, diagnosis of, 
April, 194 
treatment of, April, 203 
Pyelitis, cholecystitis, and appendicitis, 

differentiation, Dec, 1103 
Pylorus, occlusion of, by use of ligamen- 
tum teres, June, 585 



Radium in cancer, Oct., 1057 

Radius and ulna, fracture of, exhibition 

of case, Feb., 146-148 
Rectal examination in tuberculosis of 

testicle, Feb., 81 



Rectum, carcinoma of, with ulceration, 
Aug., 775 
history of case, Aug., Tjs 
operation in, Aug., 776 
Recurrent cholecystitis, Dec, 1103 
history of case, Dec, 1103 
operation in, Dec, 1104 
dislocation of patella, Aug., 839 
history of case, Aug., 839 
operation in, Aug., 840 
Renal calculus, symptoms and signs, 

Oct., 871 
Retroperitoneal hernia, Aug., 635 
sarcoma of upper abdomen, Dec, 
1215 
history of case, Dec, 12 15 
operation in, Dec, 121 7 



Sarcoma, intrathoracic, starting from 
vertebral column, differential diag- 
nosis, Oct., 883 
of humerus, .4wg., 783 
history of case, Aug., 783 
operation in, Aug., 784 
of ovary with rotation of pedicle, 
June, 599 
history of case, June, 599 
operation in, June, 600 
of testicle, Feb., 72 
of tibia, Dec, 1133 

history of case, Dec, 1133 
operation in, Dec, 1134, ''^^ZS 
transplantation of bone in, Dec, 

1134, 1135 
relation of trauma to, June, 413 
retroperitoneal, of upper abdomen, 
Dec, I 2 15 
history of case, Dec, 12 15 
operation in, Dec, 121 7 
Semilunar cartilage, internal, fracture 
of, Dec, 1 151 
and dislocation of patella, Feb., 

151 
Septic adynamic ileus, Aug., 626 
cholangitis, angulation temperature 
of, Feb., 175 



1236 



INDEX TO VOLUME III 



Scrodiagnosis of pregnancy, Abder- 
halden's,^^«7, 206; Z>6C., 1087 
technic, Dec., 1089 
Sexual desire in tuberculosis of testicle, 

Feb., 81 
Sigmoidostomy, iliac, in cancer of rec- 
tum, ^«^., 775 
Sign, Kemig's, in meningitis, Oct., 904 
Spinal cord, traumatic compression of, 

laminectomy for, Feb., 161 
Spine, fracture-dislocation of, at level 
of twelfth dorsal vertebra, 
Dec., 1077 
diagnosis, Dec., 1077 
history of case, Dec., 1077 
operation in, Dec., 1079 
symptoms, Dec, 1077 
Spinofacial nerve anastomosis, Aug., 

745, 751 
Stomach, carcinoma of, Feb., loi 
at cardiac orifice, June, 459 

history of casfe, June, 459 
grafting of, on gastric ulcer, Feb., 

lOI 

diseases of, gastric analyses in, Feb., 

lOI 

lesser curvature of, penetrating ulcer 
on, June, 585 
history of case, June, 585 
operation in, June, 589 
ulcer of, Feb., loi 
duodenal ulcer and, differentiation, 

June, 428 
grafting of malignant disease on, 
Feb., loi 
Stones in cystic duct, April, 237 
Subcoracoid fracture-dislocation of head 
of humerus, June, 539 
operation in, June, 539 
Suboccipital decompression for cere- 
bellar timior, Aug., 805 
Surgical neck of humerus, fracture of, 

nailing, /m»c, 531 
Syphilis of testicle, Feb., 71 



TAcHE c6r6brale in pneumococcus 
meningitis, Oct., 911 



Temperature angulation of septic 
cholangitis, Feb., 175 
in mechanical ileus, Aug., 651 
Tendon substitution, June, 467 

transplantation, June, 467 
Tendons, flexor, and median nerve, 
traumatic division of, 
June, 517 
history of case, June, 517 
operation in, June, 51 
Tenoplasty, June, 467 

after-treatment of, June, 470 
and neuroplasty in traumatic division 
of flexor tendons and median nerve, 
June, 517 
on wrist, June, 513 
history of case, June, 513 
Test, Abderhalden, in pregnancy, Dec., 
1087 
technic, 1089 
in tubal pregnancy, April, 206 
Testicle, carcinoma of, Feb., 72 
ectopia of, April, 217 

history of case, April, 217, 219, 231 
operation in, April, 217, 220, 231 
gummatous tumor of, Dec., 1197 

history of case, Dec., 1197 
hernia of, in tuberculosis of testicle, 

Feb., 80 
malignant disease of, Feb., 72 
tumors of, routes of metastasis 
and clinical course, Oct., 874 
paraffin substitute for, Feb., 65 
sarcoma of, Feb., 72 
syphilis of, Feb., 71 
tuberculosis of, Feb., 65 
differential diagnosis, Feb., 82 
etiology, Feb., 77 
hematuria in, Feb., 79 
hernia of testicle in, F«6., 80 
history of case, Feb., 65 
hydrocele in, Feb., 80 
operation in, Feb., 66 
prognosis, Feb., 83 
rectal examination in, Feb., 81 
routes of extension, Feb., 82 
sexual desire in, Feb., 81 
symptoms, Feb., 77 



INDEX TO VOLUME III 



1237 



Testicle, tumors of, Feb., 71 
Thrombosis of portal vein, Aug., 628 
Thyroid gland, anatomy of, April, 285 
embryology of, April, 285 
physiology of, April, 285 
Thyroiditis, acute, April, 295 
Tibia and fibula, fracture of, exhibition 
of case, Feb., 137-140 
and OS calcis, removal of nail from, 

Oct., 1003 
and patella and femur, bony ankylosis 
between, Feb., 49 
history of case, Feb., 49 
operation in, Feb., 50 
external tuberosity, impacted frac- 
ture of, Dec, 1 1 23 
history of case, Dec, 11 23 
operation in, Dec, 11 24 
osteomyehtis of, exhibition of case, 

Feb., 143 
sarcoma of, Dec, 1133 
history of case, Dec, 1133 
operation in, Dex., 1134, 1135 
transplantation of bone in, Dec, 

1134, 1135 
upper end, exostosis of interarticular 
surface, Dec, 1151 
history of case, Dec, 1151 
operation in, Dec, 1151 
Tonsillitis, metastatic arthritis of hip 
following, Aug., 681 
history of case, Aug., 681 
operation in, Aug., 683 
Transplantation of bone, Feb., 120, 121 
in sarcoma of tibia, Dec, 1134, 

1135 
indications for, Feb., 123 
of ovary, Feb., 124 
tendon, June, 467 
Trauma, relation of, to carcinoma, June, 

413 
to sarcoma, June, 413 
Traumatic compression of spinal cord, 
laminectomy for, Feb., 161 
division of flexor tendons and median 
nerve, June, 517 
history of case, June, 517 
operation in, June, 517 



Traumatic epilepsy, Oct., 931 
history of case, Oct., 931 
operation in, Oct., 932 
Tubal pregnancy, Abderhalden test in, 

April, 206 
Tubercula intercondyloidea, Dec, 11 53 
Tuberculosis of bladder, treatment, 
Feb., 76 
of kidney, Feb., 76; April, 303 
history of case, April, 303 
operation in, April, 304 
of prostate, Feb., 75, 76, 81 
of testicle, Feb., 65 
differential diagnosis, Feb., 82 
etiology, Feb., 77 
hematuria in, Feb., 79 
hernia of testicle in, Feb., 80 
history of case, Feb., 65 
hydrocele in, Feb., 80 
operation in, Feb., 66 
prognosis, Feb., 83 
rectal examination in, Feb., 81 
routes of extension, Feb., 82 
sexual desire in, Feb., 81 
symptoms, Feb., 77 
Tuberculous epididymitis, bilateral, 
Dec, 1 189 
history of case, Dec, 1189 
operation in, Dec, 1189 
Tuberculum intercondyloideum laterale, 
Dec, I 153 
mediale, Dec, 1153, 1155 
Tuflfier on transplantation of ovary, 

Feb., 124 
Tumors, cerebellar, Aug., 805 
history of case, Aug., 805 
operation in, Aug., 806 
gummatous, of testicle, Dec, 1197 

history of case, Dec, 1197 
malignant, of kidney, routes of metas- 
tasis and clinical course, Oct., 

874 
of testicle, routes of metastasis and 
clinical course, Oct., 874 
of bladder, classification, April, 341 
of breast, malignant and benign, 
differentiation, June, 413 
varieties, June, 413 



1238- 



INDEX TO VOLUME HI 



Tumors of intestines as cause of 
mechanical ileus, Aug., 639 
of testicle, Feb., 71 

of uterus, relation, to menstrual flow, 
Aug., 653 
Tyrotoxicon poisoning as cause of 
dynamic ileus, Aug., 630 



Ulcer, duodenal, April, 261 
duodenal area in, April, 268 
gastric ulcer and, differentiation, 

June, 428 
history of case, April, 261 
Of>eration in, April, 263 
pain in, April, 272 
perforating, Dec., 1205 
history of case, Dec., 1205 
operation in, Dec., 1206 
gastric, Feb., loi 

duodenal ulcer and, differentiation, 

June, 428 
grafting of malignant disease on, 
Feb., loi 
penetrating, on lesser curvature of 
stomach, June, 585 
history of case, June, 585 
operation in, June, 589 
Ulna and humerus, bony ankylosis 
between, following fracture of 
olecranon, June, 523 
and radius, fracture of, exhibition of 

case, Feb., 146-148 
fracture of, ununited, Feb., 115 
history of case, Feb., 115 
operation in, Feb., 116 
Ulnar nerve, neuroma of, April, 369, 375 
history of case, April, 369, 375 
operation in, April, 369, 375 
Ureteral calculus, symptoms and signs, 
Oct., 871 



Urinary infection, ascending, acute 
appendicitis, and cholecystitis, dif- 
ferentiation, June, 452 
Uterus, bicomate, associated with 

fibroid, pregnancy in, diagnosis of, 

June, 445 
fibroid of, Aug., 653, 761 

history of case, Aug., 653, 761 

operation in, Aug., 762 

prognosis, Aug., 659 
tumors of, relation, to menstrual flow, 

Aug., 653 



Vaccine therapy, Dec., 11 19 
Vaccines, autogenous, auto-sensitized, 

Dec., 1 1 19 
Vein, portal, thrombosis of, Aug., 628 
Ventral hernia, postoperative, following 
appendiceal abscess, Aug., 
861 
history of case, Aug., 861 
operation in, Aug., 862 
Vertebral column, intrathoracic sar- 
coma starting from, differential diag- 
nosis, Oct., 883 
Vesical papilloma, April, 337 
fulguration in, April, 351 
Volkmann's contraction in fractures, 

Feb., 142 
Vomiting in mechanical ileus, Aug.^ 650 



Wheel, diagnostic, April, 195 
Wrist, tenoplasty on, June, 513 

history of case, June, 513 
Wrists, bony ankylosis of, arthroplasty 
for, Dec., 1159, 1173 



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